Week 9/2 Depression III Flashcards
Cognitive and behavioural processes to target
Cognitive
Depressogenic thinking
Behavioral processes to target
Low reinforcement and negative life event
Skill deficits (social for ex.
CBT Model of Depression
Underlying diathesis-stress model
Personal diatheses interact with stressful life events to disrupt
normal mood
Depression maintained by negative cognitive and behavioral processes
Emotional Spirals (linked to depression)
Depression may begin, or deepen, as part of a DOWNWARD EMOTIONAL SPIRAL
Negative events may breed negative moods… negative moods, negative behaviors … and negative behaviors, may produce negative thoughts and expectations for the future
Remember, works both ways, downward and upward.
Positive triggers can start a chain of pleasant feelings, events, and thoughts.
Therapists, work a an experiment.
Cognitive Techniques in CBT
Goal is to?
help youths LEARN how to:
Observe their thoughts, feelings, and behavior
Consider alternative explanation
Solve problems and make rational decisions
Therapy as observation and experiment
Assess the accuracy and affective consequences of their
thinking
Try correcting your thought and see what happens (like experiement, collect data)
Match developmental level
Use of concrete examples and cartoons
Garfield example comic. Event, gbeliefs, cognitive, alternatives. Bad parent/being, really isolated incident.
Saw examle of homework and keep data of
Mood?
Reason grade on test. Alternatives and actions!
Negative thoughts are risky!
Rumination if no alternatives found so start with behavioural techniques.
Behavioral Techniques in CBT
Keep track of mood and activity
How do you feel?
What are you doing?
Develop list of rewarding activities
Activities that produce pride
Activities that produce pleasure
Are these good rewarding activities? not?
Taking a long walk
Talking on the phone
Being on a baseball or softball team Volunteering at the local soup kitchen
Why or why not
Walkin (location,mle try of time and ruminating need to weigh)
Talking,
Softball team
Volunteering soup kitchen
Remember very small things are often enough. Food book, TV.
Change habits, cbt and depression
Address environmental obstacles
Address skill deficits,
Monitor IMPACT and refine plan obviously follow up.
Need tangible data to prove to ppl
Cbt is working.
Antidepressant Medication, to treat depression.
Developmental differences
Many effective medications for adults
Some do not work at all in children
Most do not work as well in adolescents
May be due to differences in brain development or metabolism, but are unsure
So not a 1:1 cordon dance between kids and adults
Tricyclic antidepressants, for depression
Prevent the reuptake of norepinephrine and serotonin in the synapses or by increasing the
responsiveness of receptors to these neurotransmitters
No evidence of efficacy in youth
Monoamine oxidase inhibitors (MAOIs) for depression
MAO is an enzyme that breaks down some neurotransmitters
MAO inhibitors stop this enzyme thus increasing the level of neurotransmitters in the synapse
Some mixed evidence of efficacy in teens
Potentially lethal side effects
Interacts with foods rich in a particular amino acid (tyramine) and can lead to a potentail fatal increase in blood pressure
Red wine, beer, chocolate, aged/ripened cheese
Selective serotonin reuptake inhibitors (SSRIs) for depression
Inhibit the reuptake of serotonin so that more is available in the synapse
Similar to tricyclics, but more specifially focused on serotonin
Good evidence for fluoxetine (Prozac) in teens
Tend not to be fatal in overdose
Side effects: agitation, jitteriness, anger, hostility, nausea, stomach cramps
Antidepressants for Children and Adolescents contd
SSRIs show some evidence of efficacy
Suggestion of increased risk of suicide!
Black-box warning by the FDA
Appears on the package insert for medication
Warns of serious adverse side effects
Most serious warning the FDA gives
Named for the black border around the warning
Black-Box Warning history for ssri (like Prozac)
Began with concern about one particular type of drug (Paxil)
FDA requested data from all RCTs involving antidepressants
Nine different drugs, 25 trials
Independent team of experts conducted analyses
Found higher levels of suicidal thoughts and behavior in patients treated with antidepressants compared to placebos
No deaths from suicides were observed in these trials (+4000 patients)!
Similar findings in a follow-up study with more patients
But….
Studies not involving RCTs have shown that use of antidepressants is associated with decreased suicidality
Epidemiological data indicates that as use of antidepressants goes up, suicidality goes down
Note that adolescent suicide rates in the US increased for the first time in 2004, after many years of decrease
Speculation that this was, in part, due to adolescents not being treated for depression, scared by warning.
Most Recent Study
Gibbons et al. 2012
Obtained complete longitudinal data from RCTs for Prozac (fluoxetine) from the drug companies and the Treatment for Adolescents with Depression (TADS) study
Built on previous studies by including additional data
Examined association between treatment group and clinician ratings of suicidal ideation as well as adverse event reports
Did not find higher rates of suicidal ideation in youth treated with Prozac compared to placebo
Decrease of antidepressant use shows increase in suicide. Due to black box warning. No difference in actual suicides, not enough power perhaps. Only looked at poisoning method.
Also looked at adults, not included in black box warning, still saw decrease. No chance either.
Antidepressant Use in Children and Adults
where are w know in. The debate?
Evidence on whether the SSRIs increase suicidal ideation in children is characterized as mixed
Balancing risk and benefit
Possible increase of suicical ideation
Risk of suicidal ideation of depression is left untreated
Some evidence that some SSRIs (e.g., Prozac) may confer acceptable benefit:risk ratio for adolescents
Treatment for Adolescents with Depression Study (TADS), like that adhd MTA one.
CBT
Evidence for CBT in treating youth depression
10 RCTs suggested CBT was efficacious
40% of patients did not respond
Significant relapse rates for those who do improve
Room to improve treatment
Medication
One RCT suggesting Prozac was efficacious
SSRIs were increasingly being used, making it important to examine it’s effectiveness in a sample of depressed adolescents
Combination
Clinicians often recommended combined SSRI and CBT
Not clear how they compare to each other, or if the combination is more beneficial then either alone
TADS Goals
Using a sample of patients representative of those ofound in clinical practice:
(1) What is the effectiveness of pharmacological treatment for depression in adolescents?
(2) What is the effectiveness of CBT for the treatment of adolescent depression?
(3) How do these treatments compare?
TADS
Participants – 13 sites
– 439 youths enrolled
– age 12 to 17
– 54% female
– MDD, moderate to severe
Design
– Random assignment
– CBT, SSRI, CBT+SSRI, pill placebo
– Treated for 12 weeks
Active medication, by self or in combination.
Showed improvement, compared to no meds. By self and Therapisr.
So on average meds helps.
Combination group aside.
Cbt might be helpful for suicidality
Reccomened combo for moderate to severe depression.
Overall, groups with active medication did better in terms of depression symptoms. Rocked world of therpay, not cbt. Why?
Not a lot of support for CBT, only in combination for Suicidality.
CBT did not outperform a pill placebo
Contrasts with previous evidence
Why? (3 reasons)
Sample characteristics
Some evidence that CBT may not work as well in a more severe
sample
TADS sample was very severe
Treatment manual
Very flexible
Therapists given a lot of latitude in picking from different “modules”
May have resulted in participants getting fewer CBT techniques
TADS Follow Up
Initial TADS results for 12 weeks of treatment
Actually conducted 36 weeks of treatment
After 12 weeks, SSRI and placebo groups unblinded ethical reasons
Placebo non-responders got treatment
Placebo responders were monitored
Over time no difference! Cbt just takes longer. But lacks control of untreated. Cbt could be natural remission line.
It is possible that the severity of sample may have meant that CBT alone took longer to work
Suicidal ideation is significantly more common in those treated with medication alone, compared to both CBT and combined treatment
TADS Follow Up
Initial TADS results for 12 weeks of treatment
Actually conducted 36 weeks of treatment
After 12 weeks, SSRI and placebo groups unblinded ethical reasons
Placebo non-responders got treatment
Placebo responders were monitored
Over time no difference! Cbt just takes longer. But lacks control of untreated. Cbt could be natural remission line.
It is possible that the severity of sample may have meant that CBT alone took longer to work
Suicidal ideation is significantly more common in those treated with medication alone, compared to both CBT and combined treatment
No treatment control , a limitation
Artuable.
Unethical,
And remission rate is not this fast, as it was for those having cbt! So faster than nature.
Summary of tads.
CBT for child and adolescent depression can be effective
May not be the best choice for severe cases
Evidence for the effectiveness of SSRIs
Have to weigh the risks and the benefits
TADS authors concluded that CBT in combination with SSRIs may prove protective against suicidality
Treatment for Depression in Preschoolers
Diagnosis of depression in preschoolers is very new
Not much is known about effective treatments
As of 2006, no studies had examining the safety and efficacy of prescribing medication for preschool mood disorders
Also no psychotherapy trials
Note that prescribing occurs “off-label”
3-9/1000 U.S. preschoolers treated with psychotropic meds in the 1990s
Most common prescriptions are for stimulants, adhd meds
Treatment for Depression in Preschoolers
Luby and colleagues have developed a version of parent-management training that focuses on helping parents learn to manage their children’s moods
Therapy is recommended as the first approach
If symptoms are severe and persist, fluoxetine (Prozac) has the best risk/benefit profile in older children and is recommended as the first choice in preschoolers
