Depressive Disorders- unipolar

Symptoms and disorders across development

• Same underlying symptoms of depression may be expressed differently

• Different causal processes at different ages

• Symptoms and processes may be relate to other development processes (peer relationships, pubertal development

Mood and Depressive Disorders

Unipolar depressions

Bipolar depressions

Major Depressive Disorder

Criteria:

• At least one major depressive episode

• No history of manic, hypomanic or mixed episodes

• Must display 5 of 9 symp, one must be the first 2 symptoms for at least 2 weeks

• Symptoms

  • Depressed or irritable mood

  • Anhedonia

  • Weight loss or gain

  • Sleep

  • Psychomotor agitation or retardation

  • Fatigue/energy

  • Worthlessness/guilt

  • Thinking/concentration probs

  • Thoughts of death/suicidal ideation

Persistent depressive disorder

Criteria: Depressed or Irritable mood (required) plus 2 or more additional symptoms, lasting at least a year in youth and 2 in adults

• Poor appetite and overeating

• Sleep disturbance

• Low energy or fatigue

• Loss of self-esteem

• Concentration or decision-making problems

• Feelings of hopelessness

Or major depressive episode that lasts for a long time

Double Depression

• Persistent Depressive Disorder PLUS major depressive episode

Disruptive Mood Regulation Disorder

Criteria

• severe temper outbursts (aggression and rage) out of proportion

• inconsistent with developmental level

• outbursts occur 3 or more times per week

• irritable/angry mood between bursts, most of the day nearly everyday

• more than 12 month with no more than 3-month break

• 2 settings (school, home, peers) severe in 1

• not diagnosed before age 6 or after 18 for first time

  • symp must have been present before age 10

• no hx of mania

• not exclusively during depression

Premenstrual dysphoric disorder

• mood and irritability disturbance the week before menses

• resolves with onset of menses

• can include labile, depressed or anxious mood

• Also can include poor concentration, lethargy, decreased interest, swelling/pain, bloating, disturbed eating and/or disturbed sleep

Dimensional perspective

• depression goes along with anxious/withdrawn behavior in youth

• importance of looking at subsyndromal depression

comorbidity

• anxiety, esp starting before the depression

• conduct

• Adhd

• Eating disorders

• Substance abuse

Depression is not rare

• By age 18, 11.7% of adolescents have had an episode of mdd or a depressive disorder

• including children and adolescents who are symptomatic without meeting criteria rates are even higher

• median age of onset = 13

Homotypic and Heterotypic Continuity

• homotypic continuity

  • observable manifestations of underlying construct stay the same over time

• heterotypic continuity

  • observable manifestations of the underlying construct change over time

Depression and children and adolescents

• show more irritability than sadness

• onset at adolescence, gender effect starts

• Adolescent onset

  • most likely lead to homotypic continuity (stable presentation of depression over time)

  • hopelessness expressed later

• Child onset is rare but more likely to turn into DD

• Child onset could become bipolar, esp with bipolar relative or comorbid ADHD or CD

Infancy - depressed behaviors look different

• Infants separated from caregivers

  • less active

  • more withdrawn

  • eating and sleeping problems

Preschool

• Irritability

• Changeable mood

• Eating and sleeping problems

• Sadness and crying

Adolescent and adult course

• Episodic and recurrent

• Average length of episode

  • 2-9 months but large range

Depression and RDoC

• Overactivity in negative valence systems

  • some heritability in rumination

• Underactivity in positive valence systems

  • reward sensitivity, reinforcement learning, decreased motivation

Genes and heredity

• heritability data show mixed results depending on the kind of study, but depression is at least moderate heritability (20-70%)

• Genes controlling activity of neurotransmitter systems esp that control breakdown of monoamines serotonin, dopamine, norepinephrine

  • Monoamine Oxidase A gene controls enzyme MAO A, —> breaking down monoamine neurotransmitters

  • Catechol-O-methyltransferase gene controls synthesis of COMT, enzyme that breaks down neurotransmitters

  • Serotonin transporter gene 5-HTTLPR : 1 or 2 copies of short allele combined with child maltreatment increases risk of depression

Additional genes

• Genes affect BDNF, helps neuron growth and survival

  • main effect and interactions w child maltreatment

• Genes affecting HPA axis- stress response (cortisol)

Other genetic vulnerability factors

• genes probably affect other vulnerability factors

  • temperament

  • cognitive style

  • stress reactivity

  • hormone and NT systems

Gene x Environment interactions

• gene only lead to depression in presence of some environmental factor

RGE: Gene-environment correlation

• Passive— genes in individual and parents

  • e.g negative thinking styles modeled by parents, child has genes and also learns those thinking styles

• Evocative— evoke response

  • child gets genes that lead to being low energy or negative and thus get less reinforcement from parents and others

• Active- environment selection

  • Child inherits genes that causes them to select environments that support depression, reinforce avoidance

Temperament

• High negative emotionality

  • Negative affectivity

  • Neuroticism

  • Behavior inhibition

• Low positive emotionality/surgency (low— in depression not anxiety)

  • Positive affectivity

  • Approach

  • Extraversion

  • Behavior activation

Conceptual Models

• Additive

  • balance among vulnerability and protective factors

• Multiplicative

  • synergistic product of risk factors becomes cumbersome to study with multiple levels of risk

• Weakest link model

  • similar mediating pathways but most depressogenic vulnerability is best risk maker

Emotion

• Problems in emotion recognition and processing

  • Difficulty accurately identifying emotions in others

  • problems in identifying own emotions

• Problems in emotion regulation

  • early adverse experience

  • problems in family environment/parenting

  • associated neural processes—deficits link to low activity in neural reward circuits, also altered neural activity during emotion regulation tasks

  • differences may increase during development esp puberty

Cognitive factors in depression—drawing from adult life mainly

• cognitive factors increase in importance toward and through adolescence

• perhaps caused by and interact with stressful life events

• unclear if they remain after end or recovery from episode

• parenting seems highly related; maternal negative cognition may play a role, interact with life events

Cognitive factors continued

• negative views of self, world and future

• learned helplessness then hopelessness

• attributional style

  • internal global stable

• rumination and self focused attention esp brooding

  • repeatedly focusing on negative emotions or events

Cognitive information processing in depression

• bias towards negative stimuli

• Negative appraisals of own competence (underestimated)

• Overestimation of the stressfulness of situations and self contributions to it

• Accuracy and timing are not clear on these processes

• Links between cognitive vulnerability and depression increase with age

Self regulation/coping

• Depressed children cope differently

  • less active coping

  • more avoidant coping

• At risk children

  • poor inhibition of negative effect

  • tendency to focus on sad facial expressions

  • poor self regulation and distraction coping

Stressful life events/trauma

• prenatal stress can increase risk of depression

• variety of stressful life events predict depression

• cumulative and multiple stressors worse

• Interpersonal stressors when child is interpersonally dependent

Interpersonal/family relationships

• Parenting

  • Low warmth

  • High hostility

  • high controlling

  • rejecting

• Can be difficult through adolescence

• transactional relationship

• parental depression

Peer

• Peer problems

  • contribute to stress in relationships

  • have aversive encounters

  • are rejected

• Social skills deficits

  • excessive reassurance seeking

  • negative feedback seeking

  • social withdrawal

  • ineffective responses to peer stressors

• Deviant peer associations

• romantic relationships

• co-rumination

Treatments for Depression

• CBT most supported therapy aside from medication

• May be best with mild of moderate symptoms vs severe

• May reduce need for other services

• can be combined with medication

  • esp if cognitive distortions and depression not too severe

• In some cases it does not seem to add benefit to medication alone

CBT for depression

• Safety planning

• mood monitoring

• behavior activation-schedule more please activities

• problem-solving

  • STEPS

• Cognitive therapy— challenge unhelpful thinking styles

  • catastrophic thinking, dichotomous thinking

• Relaxation

  • paced breathing, PMR

Acceptance and Commitment Therapy

• less change more acceptance

• acceptance of a full range of emotions

• Mindfulness and present moment awareness

• less support than traditional CBT

Interpersonal therapy-adolescent

• social relationship factors are involved in maintain depression, regardless of other reasons (e.g biological)

• 12 session therapy aimed at helping with social relationships in one of 4 areas

  • role dispute

  • role transition

  • interpersonal deficit

  • grief

Contraindictions for IPT

• Active suicidality

• Substance abuse

• Significant intellectual disability

• Bipolar disorder

IPT content

• Psychoeducation—depression and the sick role

• techniques for affect identification

• Interpersonal skills building

  • modeling/feedback from therapist

  • communication analysis

  • perspective taking

  • problem solving

  • role playing

Psychodynamic Psychotherapy

• Different types of psychodynamic therapy

• Often focus on bringing emotions and conflict into awareness limited support

Family Therapy

• Usually aimed at resolving conflict and reducing negative interactions within fam

• Attachment-based family therapy—ABFT—has some support

• Family Psychoeducation—improves family relationships

Modular Approach to Therapy for Children (MATCH)

• Algorithm-guided modular treatment for comorbid depression and other
  disorders

• Others combined CBT with Family therapy for other disorders
  

Transdiagnostic approaches

• Target processes underlying two or more disorders, e.g., depression and anxiety

  • e.g., Behavior activation plus exposure (Chu)

  • Emotional awareness, preventing avoidance, cognitive interventions promoting flexibility and challenging negative thinking (Ehrenreich-May)

Computerized CBT

• May be promising

• Not alot of data yet

• Maybe good for mild to moderate

Medication and other therapies

• Fluoxetine (prozac)

• Escitalopram (lexapro)

• increased risk of suicidal behavior

• other treatments under reserach

  • Exercise

  • light therapy

  • repetitive transcranial magnetic stimulation