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).
Interpersonal and environmental stressors
Relationship conflict Significant life changes Socio-economic hardship Loss Racism Traumatic event DV etc.
Social stressors and depression
Personality styles identified as potential risk factors:
high levels of general anxiety => worrying, catastrophizing increases risk of depression
“shy” people >not just genetics - if bullied or humiliated early years => view social interactions with others as threatening in comparison to safety of own company
“hypersensitive” to judgement by others => praise and/or feeling (perhaps inappropriately) being rejected or abandoned => Coping? increased sleeping & craving certain foods that may settle emotional state
“self-focused” individuals – presenting hostile & volatile behaviours with others, & blame others when things go wrong. Focused on own needs. When depressed => tend to show a “short fuse” => can create collateral damage for those around them
neglect or abuse in early years => low basic self-worth => tendency to repeat such cycles of deprivation and abuse in adult relationships => readily become depressed
perfectionists when prone to self-criticism and loss of pride => may also have a limited range of adaptive strategies to stress.
Brain imaging implicates different regions in non-melancholic depression: key site = amygdala -> shows heightened responsiveness when person is depressed; cortisol low
Depression: Cognitive Factors
Learned Helplessness/Hopelessness (Seligman)
–People prone to depression expect that they are helpless to control aversive outcomes, & behave accordingly.
Internal, stable, global attributions for negative events
–“I failed the exam because I am stupid (internal), I will always fail/be stupid (stable) at everything (global)”
External, unstable, specific attributions re positive events
–“I only passed the exam because Sally helped me (external). It doesn’t mean I will always (unstable) pass everything (specific)”
Cognitive factors
CT - Beck:
- -Dysfunctional beliefs related to 3 main schemas + lack of attention to positives => negative attention bias
- -“I am defective of inadequate”
- -“Everything I do results in failure” – “I am a failure”
- -“Things will never change” – “The future is hopeless”
- -Rumination
MBCT - William, Segal, Teasdale & Kabat-Zinn
- -Particularly recommended for treatment resistant depression with > 3 episode
- -Re-activation of patterns of self-devaluative depressogenic thinking experienced in previous episodes is increased with repeated episodes more internal triggers & less external triggers
- -Mindful awareness of reactivation of depressogenic thinking –> disengagement from ruminative depressive cycles
- -MBCT less effective if 1 or 2 episodes of depression) > Ma & Segal, Jnl. of Cons. and Clin. Psych., 2004)
Behavioural Factors
Disengagement from activities – experiential avoidance
Assumption that feeling good needs to precede becoming active
Withdrawal from relationships – expectations? avoiding conflict? lack of skills
Lack of rewarding activities increases low mood
Integrative Model of Depressive Disorders
slide 34 for visual
Biological Vulnerability
|
Psychological Vulnerability
|
Stressful Life Events
|
activation of stress hormones, wide ranging effects on neurotransmitters |||||| -ve attributions, sense of hopelessness dysfunctional attitudes, negative schemata ||||||||||| problems in interpersonal relationships, and lack of social support
\\\\||||||||||||||||////////////
MOOD DISORDER
Treatment Approaches
CBT
ACT
Mindfulness-based CBT
BA
IPT
Exercise
Psychiatric treatments (drug treatments, ECT)
CBT Components
Cognitions: identify & challenge cognitive distortions & negative automatic thoughts => develop more balanced thoughts
–ABCD approach
Core beliefs around self-worth & competence => produces negative automatic thoughts
Similar process to social anxiety, content of thoughts different
Include: Identifying cognitive distortions
Behaviour: identify & change aspects of behaviour that perpetuate depression
Cognitive Formulation of Depression
see slide 37 for vis
Early Experience > Dysfunctional Assumptions > Critical Incident > negative automatic thoughts <> Symptoms
smyptoms:
- behavioural
- motivational
- affective
- cognitive
- somatic
ACT Conceptualising Factors
Pursuit of value-incongruent goals: “ when you reach the top of the ladder & find it was against the wrong wall” (Shellenbarger, 2005)
—–“Success” depression
Failure to pursue value-congruent goals:
- -A life of quiet desperation (Thoreau)
- –Absence of meaning/purpose
- -Lethargy & apathy => why bother?
- -Existing vs flourishing
- -More focus on short-term hedonic pleasure
ACT Conceptualising Factors
EA & CF
Experiential Avoidance
- -Running away from/trying to control dysphoria
- -Numbing effect: prefer numbness to taking risks, potentially experiencing more pain…resulting from hoping, trying & being disappointed
- -Social disengagement protects from further rejection…all about avoiding possible unpleasant emotions
Cognitive fusion
- -With ruminative stories, negative evaluations & predictions
- -With feelings-based decisions: “I’m too depressed to…”; “I don’t feel like…”
Metacognitive Process: Rumination
Mindfulness & Acceptance-base processes do not work with the cognitive content
Rumination as a meta-cognitive process
Client first needs to understand the futility/costs of rumination
Learn to identify the ruminative process
- —It’s the “everything is shit” story
- —“I am reliving that conversation”
Notice that attention is focused inside the mind
Notice that attention is not focused on what is present
Decentre: externalise attention to what is present
Repeat
Repeat
Repeat
Notice the 5 Things
Using self-talk:
- -Name 5 things you can see
- –Name 5 things you can feel against you
- –Name 5 things you can hear (context-dependent)
In-session, have the client say them aloud, & encourage more specific & detailed descriptions
Long enough to detach from ruminative (& worry) processes
Focus on what is real & present vs what is happening in the mind (usually neither real nor present)
Cognitive Defusion
Defusion: detaching/decentering from (but not suppressing) thoughts
Thoughts are merely sounds, words, stories, bits of language that pass through our minds
Thoughts may or not be true; we don’t have to automatically believe them
Thoughts may or may not be important or helpful
Thoughts are not orders. They do not have to be obeyed
Thoughts may or may not be wise
Defusing techniques…
Visualisation of thoughts passing (clouds across the sky; leaves on a stream; the doorman metaphor)
“I’m having the thought that…/I’m noticing the thought that…”
Thank your mind
Name the story (“this is the ‘I can’t do anything right’ theme again”)
Hear thoughts in Donald Duck voice, Gandhi accent, sing them to the ‘Happy Birthday’ tune
NOT working with or analysing the content/positive thinking
Interpersonal Factors
Depressed people talk less, initiate conversation less, have blunted non-verbal expressions, distribute attention in groups unevenly, respond more slowly, “reward” others in conversation less
This is reciprocated by interactional partners => Reinforces & confirms whatever depressive core belief is held
Continual withdrawal/rejections of invitations => social support network dwindles
BA to re-engage with social networks
IPT rationale
Depression, despite multifaceted pathways, often occur in social & interpersonal contexts
Goals:
–Understand relationship between onset & fluctuation in symptoms & current interpersonal problems
–Assess historical and current interpersonal factors and processes
–Improve interpersonal relationships and or expectations of relationships => improve symptoms
–Improve ability to build and maintain socially supportive relationships
Treatment efficacy: IPT and paroxetine (SSRI med) on par (Brody, Saxena , Stoessel, et al. , 2001)
IPT = time-limited (12-16 sessons), interpersonally focused & psycho-dynamically informed therapy (attachment) – (For an overview read Robertson, Rushton & Wurm, 2008)
IPT: 4 focus areas linked to depression
Grief: facilitate/support the grieving process – grief related to ambiguous losses and death
Interpersonal disputes: 2 people have non-reciprocal expectations about relationship behaviours – may need to differentiate interpretations of behaviours from actual beh’s in interactions
Role Transitions: adjustment to a life change (+ve or -ve) that requires an alteration of behaviour/change to social supports or networks
Interpersonal deficits: communication deficits; lack of- fear of - assertiveness; paucity of social support
Behavioural Activation (BA)
Stressors often disrupt usual behaviour patterns
Decreased activity => decreased reward; decreased motivation & increased lethargy
- —Although depressed person feels tired, doing less will exacerbate tiredness
- —Different to non-depressed people
Decreased opportunity for pleasure/mastery, positive reinforcement
Increased opportunity for inward focus & rumination
Goal: increase frequency & quality of activity
First line of defence against anhedonia, withdrawal & fatigue
Behavioural Activation (BA)
Essential Psychoeducation:
Client Belief:
Mood (leads to =>) Behaviour
In reality:
Behaviour (leads to =>) Mood
Behavioural Activation
example
Fun activities catalogue
list of “fun” activities, client can go through and circle the ones that they may find enjoyable
Behavioural Activation
(Beck et al. 1979 manual, Jacobson et al. 1996 JCCP study)
(6 steps, what to be mindful of)
- Monitor daily activities
- Assess the pleasure and mastery achieved from activities
- Assign increasingly more difficult tasks that are likely to facilitate pleasure and/or mastery
- Cognitive rehearsal of scheduled activities (identify possible obstacles to pleasure/mastery)
- Discuss specific problems (e.g. difficulty in falling asleep) and use behaviour therapy techniques to deal with those
- Social skills training (e.g. assertiveness, communication skills)
Be mindful of:
- -Identifying avoidance behaviours and potentially reinforcing activities
- -Setting up activation strategies that are consistent with client’s life goals
Daily activities monitor
write down what you did & assess the pleasure and mastery from those activities
Implementing BA
Test predictions (behavioural experiment)
- –Rate how much pleasure/effort/difficulty they expect
- –Perform behaviour as an experiment
- –Re-rate pleasure/effort/difficulty
- –Rate mood before & after
Important: FEELING like it is NOT a necessary pre-condition for doing it
—Did you FEEL like brushing your teeth this morning??
Specific plan for behaviours
Anti-procrastination Exercise
Activity (break each task into small steps)
Predicted difficulty
Predicted satisfaction
Actual Difficulty
Actual Satisfaction
More tips re. implementing BA
Breaking the activity into sub-components very helpful
Depressed mind thinks globally & negatively by default
“It is all too hard”; “It is overwhelming”
Sub-components encourage more specific thinking
More opportunities to meet sub-goals => more reward + mastery
Graded Activation Example (1)
Goal: Re-engaging with Friends
Make a list of people person has lost contact with
Gather as many contact details as possible
Choose 1 or 2 people to contact
Choose day, time & method of contact
Discuss how to engage, what to say (role-play)
Make the call or send e-mail/message
Invite person for a catch-up
Go to catch-up, even if you don’t feel like it
Identify next person
Repeat
Graded Activation Example (2)
List all components of the BA project
Set a timeframe/understand deadline for each component
Sub-components if necessary
Prioritise in order of necessity/importance
Record amount of time necessary for each component
Schedule one sub-component each day
Monitor time spent/effort entailed in actually doing task
Rate degree of difficulty before/after
BA examples
weekly activity schedule : balance fun and pleasurable activities with your daily responsibilities and duties
rate depression, pleasure and achievement before and after the activity
Alternative BA intervention: Pleasant Events Schedule
How often have I engaged in the activity during the past 30 days?
- – 1 = Not at all in the past 30 days
- – 2 = A few times (1-6) in the past 30 days
- – 3 = Often (7 or more) in the past 30 days
How pleasant, enjoyable or rewarding was the activity during the past month?
- – 1 = This activity was not pleasant. (i.e., unpleasant or neutral)
- – 2 = This activity was somewhat pleasant (mildly/moderately)
- – 3 = This activity was very pleasant (strongly/extremely pleasant)
Efficacy of BA - 1
Jacobson et al., (1996). J. Consulting & Clinical Psychology
-Behavioural Activation (BA) or BA + Automatic Thoughts or BA + full cognitive therapy
- 151 participants
- BA was just as effective as the other two therapy conditions
- Clients in all conditions increased their frequency and enjoyability of pleasant events, decreased their negative thinking, and showed significantly lowered tendencies to attribute negative events to internal, stable, and global factors
Efficacy of BA - 2
Cuijpers et al., (2010). Clinical Psychology Review
Meta-analysis of BA treatments for depression
16 studies with 780 participants
Pooled effect size of 0.87 for difference between intervention and control conditions (large effect)
Implementing BA
Similar process across approaches
- – CBT: pleasure & mastery
- – ACT: value-congruent activities; Committed Action
- – IPT: interpersonal re-engagement
Get a baseline of existing activity
—-Very important to be non-judgemental here (client likely to feel guilty)
ALL activities may seem -overwhelming/pointless
- – What did the client USED to find enjoyable/meaningful?
- – May have difficulty thinking of them:
- —www.therapistaid.com/worksheets/activity-list.pdf
Modify to match current capacity (baby-steps)
Consider starting with any naturally occurring activities
Trouble-shooting
Client likely to find this VERY difficult
Make specific plans
—-Watch for: “I’ll try”, “if I get a chance”, etc.
—-Specify day, date, time, place
Pre-empt cognitive barriers: what will the depression tell you about this activity?
—–Defusion: thoughts are not orders; thoughts do not need to be obeyed; thoughts are not necessarily accurate
——-You can have the thought “I don’t feel like going for a walk…AS you are walking”
ACT, IPT & CBT: Compare & Contrast
CBT: Smyptom alleviation, ACT: Symptom Acceptance, IPT: Symptoms exist in social vs individual context (current & historical)
Cbt: rumination, ACT: Rumination, IPT: Innefective interpersonal relating
CBT: Behavioural Activation: pleasant events, ACT: BA = Values-congruent action, IPT: BA = socialising
CBT: Cognitive Restructuring, ACT: Cognitive Defusion, IPT: Less intra-personal focus
ACT: Role of valued living
IPT: Role transitions
e-mental health (e.g. Black Dog Institute)
myCompass is an interactive self-help service that aims to promote resilience and wellbeing for all Australians.
myCompass was developed by the Black Dog Institute and is based on CBT, interpersonal psychotherapy, problem solving therapy, positive psychology and behavioural activation. myCompass has been proven to be effective in helping people experiencing mild to moderate depression and anxiety.
THIS WAY UP Using CBT principles, the THIS WAY UP clinic offers proven online courses for depression and anxiety.
MoodGYM is a free self-help program to teach CBT skills to people vulnerable to depression and anxiety.
OnTrack offers free access to online programs, information, quizzes and advice to support people in achieving mental and physical health and wellbeing.
Some e-mental health resources for young people
BITE BACK was developed by the Black Dog Institute and is an ever-changing space which aims to improve the wellbeing and mental fitness of 12-18 year olds, based on the principles of positive psychology.
eHeadspace is a confidential, free, anonymous, secure space where 15-25 year olds can chat, email or speak with qualified youth mental health professionals.
ReachOut is a mental health website for people under 25.
Youth Beyond Blue provides mental health education and links to phone support for 12-25 year olds
