Depressive Disorders

Depression

Low, sad state marked by significant levels of sadness, lack of energy, low self-worth guilt, or related symptoms

Mania

State or episode of euphoria or frenzied activity in which people may have an exaggerated belief that the world is theirs for the taking

Depressive disorders

A group of disorders marked by unipolar depression

Unipolar Depression

Depression without a history of mania

Bipolar disorder

Disorder marked by alternating or intermixed periods of mania and depression

How common is unipolar depression? - Lifetime prevalence

20% of all adults experience unipolar depression at some time in their lives

• Female 26%

• Male 12 %

How common is unipolar depression? - 12-month prevalence

• 8 % of adults suffer from severe unipolar depression in any given year

• 5 % suffer from mild forms

How common is unipolar depression? - Onset

Average age is 19 years

How common is unipolar depression? - Remission

85% recover within 6 months

How common is unipolar depression? - Persistence

>50% have multiple episodes

Symptoms of depression

1. Emotional symptoms

2. Motivational symptoms

3. Behavioral symptoms

4. Cognitive symptoms

5. Physical symptoms

Symptoms of depression - Emotional symptoms

• Feeling “miserable,” “empty,” or “humiliated” (negative mood)

• Experiencing little pleasure (anhedonia)

Symptoms of depression - Motivational symptoms

• Loss of energy, initiative, and spontaneity

• Suicidal thinking: 6-15% of those with severe depression die by suicide

Symptoms of depression - Behavioral symptoms

Less active

less productive

speaking and movement (more slowly or agitated)

Symptoms of depression - Cognitive symptoms

• Hold extremely negative views of themselves (self-critical, blaming themselves for unfortunate events)

• Reduced ability to concentrate/make decisions

• Pessimism and hopelessness (suicide risk)

Symptoms of depression - Physical symptoms

• Disturbance of sleep pattern

• Disturbance of appetite

• Headaches, dizzy spells, or general pain

DSM-5 lists several types of depressive disorders

• Major Depressive Disorder

• Persistent Depressive Disorder

• Premenstrual Dysphoric Disorder

What is the minimum number of symptoms required for a diagnosis of Major Depressive Episode (MDE)?

Five or more symptoms, including at least one cardinal symptom from A1.

2 cardinal symptoms listed under A1 for Major Depressive Episode

1. Depressed mood most of the day, nearly every day,

2. Loss of interest or pleasure in most activities, most of the day, nearly every day.

Symptoms listed under A2 for a Major Depressive Episode

For the same 2 weeks, the person also experiences at least 3 or 4 of the following symptoms:

• Considerable weight change or appetite change

• Almost daily insomnia or hypersomnia

• Almost daily agitation or decrease in motor activity

• Almost daily fatigue or lethargy

• Almost daily feelings of worthlessness or excessive guilt

• Almost daily reduction in concentration or decisiveness

• Repeated focus on death or suicide, a suicide plan, or a suicide attempt.

Criterion B for diagnosis of Major Depressive Episode

Significant distress or impairment

Major Depressive Disorder (SCID-5-S)

• Presence of a Major Depressive Episode

• No pattern of mania or hypomania

Persistent Depressive Disorder (SCID-5-S)

• Person experiences the symptoms of major or mild depression for at least 2 years

• During the 2 years, symptoms not absent for more than 2 months at a time

• No history of mania or hypomania!

• Significant distress or impairment

Explanation models for depression

1. The Biological perspective

2. The Psychological perspective

3. The Sociocultural perspective

4. The Developmental Psychopathology Perspective

The Biological Model of Unipolar Depression

Studies of genetic factors, biochemical factors, brain circuits, and the immune system suggest unipolar depression has biological causes

• Genetic factors

• Biochemical factors

• Depression-related brain circuits

• Immune system

Genetic factors for The Biological Model of Unipolar Depression

• Family pedigree studies: 30% relatives versus 10% general population

• Twin studies: 38% identical twin versus 20% fraternal twins

• Molecular biology (e.g., short variants of serotonin transporter gene; 5-HTT)

Biochemical factors for The Biological Model of Unipolar Depression

A. A low activity of two neurotransmitters: serotonin and norepinephrine

• Early studies on high blood pressure and antidepressant drugs

• More complex relationship: neurotransmitter interaction research (glutamate)

B. Hormones and HPA pathway

• Stress-axis is overly activated (excessive release cortisol)

Depression-related brain circuits

• Brain circuit dysfunction

• Brain imaging studies

Brain imaging studies

• Subgenual cingulate makes a distinct contribution

• Abnormal activity and flow rate in various brain locations

• Structure problems: interconnectivity

• Abnormal neurotransmitter activity

Immune system for The Biological Model of Unipolar Depression

Under intense stress, dysregulation of the immune system occurs and contributes to depression

Biological approaches for Unipolar Depression : Antidepressant drugs

• In the 1950s, two kinds of drugs were found to reduce the symptoms of depression

  • Monoamine oxidase (MAO) inhibitors

  • Tricyclics

• These drugs have been joined in recent years by the second-generation antidepressants

Monoamine Oxidase Inhibitors (MAOIs) - What is the trade name for Isocarboxazid?

Marplan

Monoamine Oxidase Inhibitors (MAOIs) - What is the generic name of Nardil?

Phenelzine

Monoamine Oxidase Inhibitors (MAOIs) - What is the trade name for Tranylcypromine

Parnate

Monoamine Oxidase Inhibitors (MAOIs) - What is the generic name of Eldepryl?

Selegiline

Tricyclic Antidepressants (TCAs) - What is the trade name for Imipramine?

Tofranil

Tricyclic Antidepressants (TCAs) - What is the generic name of Elavil?

Amitriptyline

Tricyclic Antidepressants (TCAs) - What is the trade name for Doxepin

Sinequan or Silenor

Tricyclic Antidepressants (TCAs) - What is the generic name of Surmontil?

Trimipramine

Tricyclic Antidepressants (TCAs) - What is the trade name for Desipramine?

Norpramin

Tricyclic Antidepressants (TCAs) - What is the generic name of Aventil or Pamelor?

Nortriptyline

Tricyclic Antidepressants (TCAs) - What is the trade name for Protriptyline?

Vivactil

Tricyclic Antidepressants (TCAs) - What is the generic name of Anafranil?

Clomipramine

Tricyclic Antidepressants (TCAs) - What is the trade name for Amoxapine?

Asendin

Tricyclic Antidepressants (TCAs) - What is the trade name for Mirtazapine

Remeron

Second generation antidepressants-What is the generic name of Desyrel?

Trazodone

Second generation antidepressants-What is the trade name for Fluoxetine?

Prozac

Second generation antidepressants-What is the trade name for Sertraline?

Zoloft

Second generation antidepressants-What is the generic name of Paxil?

Paroxetine

Second generation antidepressants-What is the trade name for Venlafaxine?

Effexor

Second generation antidepressants-What is the generic name of Wellbutrin?

Bupropion

Second generation antidepressants-What is the trade name for Citalopram?

Celexa

Second generation antidepressants-What is the generic name of Lexapro?

Escitalopram

Second generation antidepressants-What is the trade name for Duloxetine?

Cymbalta

Second generation antidepressants-What is the generic name of Pristiq?

Desvenlafaxine

Second generation antidepressants-What is the generic name of Strattera?

Atomoxetine

Antidepressant drugs- MAO inhibitors

• Work biochemically by slowing down the body's production of MAO

• MAO normally breaks down serotonin and norepinephrine

• May cause a rise in blood pressure when combined with certain common foods

• Approximately half of patients who take these drugs are helped by them

Antidepressant drugs - Tricyclics

• Act on neurotransmitter reuptake mechanisms of key neurons

• Block an overly vigorous reuptake process and allow serotonin and norepinephrine to remain in the synapses longer

• Can produce side effects; relapse may occur if therapy is ended too quickly after recovery

Antidepressant drugs - Second-generation antidepressants

• Selective serotonin reuptake inhibitors (SSRIs)

• Structurally different from MAO inhibitors and tricyclics

• Increase serotonin activity without affecting norepinephrine or other neurotransmitter

• Fewer undesired, but still some, side effects

• Failure rate may be 40 percent or higher

Brain stimulation

Biological treatments that directly or indirectly stimulate certain areas of the brain

• Electroconvulsive therapy (ECT)

• Vagus nerve stimulation

• Transcranial magnetic stimulation (TMS)

• Deep brain stimulation (DBS) of subgenual cingulate

Cognitive-behavioral model of Unipolar Depression

Depression results from problematic behaviors and dysfunctional thinking

Theoretical perspectives in Cognitive behavioral model

• Cognitive dimension: negative thinking patterns

• Behavioral dimension: less rewards

• Complex cognitive and behavioral factor interplay

Behavioral dimension

• Number of life rewards related to presence or absence of depression

• Large reduction in positive life rewards may cause increasingly fewer positive behaviors, even lower positive rewards rate, and eventual depression

• Social rewards are important in downward depression spiral

Negative thinking

• Beck: Unipolar depression is produced by a combination:

  • Maladaptive attitudes/beliefs: “My general worth is tied to every task I perform”

  • Cognitive triad: Negative view of experiences, oneself, and future

  • Errors in thinking: negative conclusions without evidence

  • Automatic thoughts: “I am worthless …, everyone hates me .., I am to blame …

Rumination (brooding):

repeatedly dwelling on negative mood and problems

Learned helplessness

Seligman: Depression occurs when people believe they have no control over life’s reinforcements and assume responsibility for this helpless state

Attribution-helplessness theory

When people experience events as beyond their control, they ask themselves why this is so:

• Attribution to some internal, global, and stable cause (“I am worthless in everything en will always be a loser”) = depression

• Attribution to more specific, unstable, or external causes = less likelihood of learned helplessness and depression

Behavioral activation - Cognitive-behavioral therapy

Therapist works systematically to increase the number of constructive and pleasurable activities and events in a client’s life

• Reintroduce pleasurable events and activities

• Appropriately reward nondepressive behaviors

• Help improve social skills (Lewinsohn)

Most effective when combined with cognitive techniques

Beck’s cognitive therapy

Used to guide clients in four phases to recognize and change negative cognitive processes

• Phase 1: Increasing activities and elevating mood

• Phase 2: Challenging automatic thoughts (though experiment)

  • When I ask a stranger something, that person laughs at me.

  • How credible is this? Is there an alternative, and how likely is it?

    • Let's experiment and determine what counts as evidence "If someone answers my question." Formulate a decision rule and conclusion.

• Phase 3: Identifying negative thinking and biases

• Phase 4: Changing primary attitudes

New-wave cognitive-behavioral therapists

• Disagree with Beck’s proposition about the need to fully discard negative cognitions to overcome depression

• Use mindfulness training and other techniques to help clients recognize negative cognitions as streams of thinking

Family-social perspective of Unipolar Depression

• A decline in social rewards impacts depression

• Depressed people often demonstrate social deficits that may cause avoidance by others, thereby decreasing their social contacts and rewards

• Depression is tied to weak or unavailable social support, isolation, and lack of intimacy.

Family-social treatments of Unipolar Depression

Interpersonal psychotherapy (IPT; Klerman and Weissman)

• Studies suggest that IPT is as effective as cognitive therapy for treating depression

Couple therapy

Multicultural perspective of Unipolar Depression

A strong link exists between gender and depression

• Across various cultures, women are twice as likely as men to receive a diagnosis of unipolar depression

• Multicultural perspective: Gender and depression explanations

• Artifact theory

• Hormone explanation

• Life stress theory

• Body dissatisfaction explanation

• Lack-of-control theory

• Rumination theory

Developmental Psychopathology Perspective

• Posits that the interplay and interactions between biological, psychological, and social factors throughout development contribute to vulnerability and the onset of depression.

• Some key points from a developmental psychological perspective on depression include:

  • Early experiences (attachment relationships, traumas), developmental tasks, biological changes, social context, life events

  • Sequence: distal versus proximal risk and protective factors ("resilience")

  • Multifaceted