Depression ClinPsych

Name 5 psychological symptoms of depression

continuous low mood / sadness

feeling hopeless, helpless

low self-esteem

feeling teardul

guilt-ridden

irritable, intolerant of others

no motivation / interest in things

difficult to make decisions

not getting enjoyment out of life

anxious / worried

suicidal thoughts

thoughts of self-harm

Name 5 physical symptoms of depression

moving / speaking slower than usual

changes in appetite / weight

constipation

unexplained aches and pains

lack of energy

low s** drive

disturbed sleep

What do we need to remember about symptoms?

Some may just be normal

Stigma - young adults

• Mitchel et al (2017)

  • Young adults less likely to seek MH support due to stigma, negative perceptions surrounding MH - preference for self-reliance, difficulty articulating concerns, practical challenges accessing services

stigma - men

• Gough et al (2020)

  • Men less likely to seek support, more likely to commit suicide

  • 2024 - males 50-54 had highest suicide rate (Samaritans)

stigma - BAME

• Jacobs et al (2021)

  • Help-seeking in BAME individuals hindered by cultural gap - patients avoid services as they fear practitioners will dismiss cultural / religious perspectives in favour of medical models

  • Social stigma creates barrier of secrecy, individuals mask symptoms until they reach a crisis point

Structured Clinical Interviews for DSM-V (SCID)

standardised questioning format for DSM-V diagnoses

semi-structured, open-ended questions

systematic series of probes

60-90 minutes

Questionnaires / Assessment Scales examples

Hospital Anxiety and Depression Scale (HADS)

Deression Anxiety / Stress Scale (DASS-21)

Beck Depression Inventory (BDI-II)

what are Questionnaires / Assessment Scales used for

quick screening, quantifying symptom severity

Assessment Considerations

• differentiate normal vs pathological

  • normal emotional responses to loss vs pathlogical depression

• differentiate unipolar vs bipolar

  • unipolar depression is a single or recurrent depressive episodes (MDD)

• risk assessment

  • suicidal, self-harm ideation needs to be evaluated

  • assess how to provide immediate care, long-term patient support (NICE guidelines, 2022)

  • Mental Health Act (1983) section 2 allows patient to be compulsorily admitted, detained in hospital for up to 28 days for assessment, treatment, if two medical practitioners agree it is needed for own safety / of others

• comorbidity

  • check for other mental / physical health conditions

• severity classification

  • categorise depression as subthreshold / mild / moderate based on symptom count and functional impairment

Diagnosis - Severity levels

Subthreshold - under 5 symptoms required for diagnoses

mild - fewer than 5 symptoms

moderate - some symptoms and functional impairment

severe - most symptoms with the interferences of functioning, with or without psychotic symptoms

Concern about subthreshold

If people receive no treatment, symptoms may get worse, they may then develop MDD

Biopsychosocial model

• Considers complex interactions between biological, psychological, and social factors, to provide a comprehensive understanding and aetiology

Biological factors

• Genetics - family history (twin studies)

• Neurotransmitters - monoamine hypothesis (imbalance in serotonin, norepinephrine and dopamine systems)

• Neuroendocrine - hyperactivity of hypothalamic-pituitary-adrenal (HPA) axis - increased cortisol

• Neuroanatomy - changes in prefrontal cortex, hippocampus, amygdala

Psychological factors

• Cognitive patterns - Beck's model

• Behavioural patterns - Seligman's learned helplessness

• Personality traits - high neuroticism, low extraversion, perfectionism

• Early experiences - childhood trauma, abuse, neglect

Social factors

• Negative life events

• Lack of high-quality social support

• Socioeconomic status

• Cultural background

Treatment implications of biopsychosocial model

Treatment should target all relevant dimensions for optimal outcomes

What is Beck’s Cognitive model?

• Based on Cognitive behavioural principles

• Self-reinforcing cycle between thoughts, feelings, behaviours - need to break this cycle

• Early experience, core beliefs and assumptions, and perhaps a critical incident lead to negative automatic thoughts that have a reciprocal relationship between negative behaviours and feelings

How is depression reinforced according to Beck’s model?

• Depression can be sustained by negative thoughts associated with cognitive biases (Beck's two key biases - catastrophising, overgeneralisation); heightened physical arousal and responses to these thoughts often associated with anxiety; maladaptive coping mechanisms and behaviours like avoidance, self-harm, and drug use

• Reinforcement loop - avoidance can temporarily reduce depression, leading to negative reinforcement, however in the long-term depression grows and generalises to other events and situations

What is evidence-based practice?

• the use of the best available scientific evidence to make decisions, informed interventions

• Individual differences, preferences need to be considered (treatment resistance, comorbidity, QoL…)

• Continuous critical evaluation through research and practice - requires element of flexibility and transparency

• Research exploring the development of treatments for different aetiological models. In the example in part two, focus on the psychological model, more specifically cognitive and explore/ evaluates how EBP on cognitive based therapies such as CBT is used to treat depression

What is CBT?

• A here-and-now treatment that helps clients bring about the desired changes by implementing new adaptive learning with a problem-solving focus

• The therapeutic process is explicit and collaborative

• It is a time limited therapy, and goals are agreed upon beforehand

• They key goal is usually to identify, question, and test NATs

• Break the current cycle, with the patient identifying the problem themselves

• Create a NAT record, identifying unpleasant emotions, identifying situations and triggers where these occurs and identifying the associated NATs

  • This is done with the therapist in sessions at first, then turns into homework to get patients to do this independently and automatically

What is the current recommended pharmacological treatment?

• NHS England - SSRIs first-choice medicine for depression - fewer side effects vs other types of antidepressant

• Improve serotonin absorption in brain

• Serotonin - NT with influence on mood, emotion, sleep

• Fluoxetine blocks ST reabsorption, increasing the amount available at synapses which improves mood, reduces anxiety, promotes a sense of calm

NICE reccomendations

• CBT recommended most consistently (Pilling et al., 2011)

• Usually reserved for participants who haven’t responded to medication, who don’t like / can’t tolerate pharmacotherapy)

What is an active control group?

An active control group is a group of participants in a clinical trial who receive an existing, proven treatment instead of a placebo or no treatment at all. The new drug or therapy being tested is then compared against this known treatment to see how it stacks up. This design is especially common when it would be unethical to give participants a sugar pill because an effective treatment already exists.

Cuijpers (2023)

• Meta-analysis revealed a combined treatment was the most effective treatment for depression

• Possibly supports the biopsychosocial model

• CBT and pharmacotherapies showed similar short-term efficacy, but CBT was more effective at 6-12 months, showing we need to look at the true long-term effect

Cuijpers (2023) evaluation

• Only 32.1% of 409 trials were considered to have low risk of bias due to difficulty of blinding

• Biases include issues with allocation concealment, inadequate randomisation

• Effect size smaller for studies with low risk of bias

Hoffman et al. (2023) topic

• Review of 269 outcome studies (CBT + pharmacology), looking at problem areas and study populations

Hoffman et al. (2023) results

• Found mixed results for studies comparing CBT with psychodynamic treatment, problem-solving therapy, and interpersonal psychotherapy

• CBT and pharmacological treatments had similar effects on chronic depressive symptoms, but a combination was more effective than CBT alone

Hoffman et al. (2023) evaluation

• In reviews we need to consider:

  • Publication bias - inflate effect size

  • Inadequate control groups - inflate effect size

  • Small sample sizes - power

  • Lack of generalisability for subgroups

What did Barnes et al. (2013) investigate

• Investigated why clients struggle with or drop out of CBT

• Participants:18 - 75 years, currently taking antidepressants (and had done so for at least 6 weeks at an adequate dose), who were adhering to their medication, had a Beck Depression Inventory (BDI) score of more than 13, and met ICD-10 criteria for depression.

• A mixed-methods study using follow-up questionnaires and 26 in-depth interviews from the CoBalT trial.

What did Barnes et al. (2013) find?

• Challenges - practical issues e.g. time, location, homework (linked to negative school memories, fear of being judged in vulnerable, lack of self confidence / motivation moments)

• Therapy caused confusion, upset - reinforced by reports of difficult / painful therapy work - revisit negative situations, thoughts

• Dissatisfaction with aspects of relationship with therapist - important to build rapport

• Those who struggled still found value in the strategies they learned (identifying negative thought patterns, enabled them to deal more effectively with depression)

Implications of Barnes et al. (2013)

• Clinicians are encouraged to address barriers early to improve engagement (challenges of CBT e.g. homework to prepare them to make informed choices; address possible barriers during therapy to help with engagement, completion)

• Improve client-therapist relationship - address potential difficulties, emphasise collaborative nature of relationship - build rapport, could help with reflection on negative feelings

• Note here that the key is that they are aware of different types of therapy but there might be different psychological models to these therapies e.g. family therapy may also look at social and environmental influences.

Barnes et al. (2013) evaluation

• CBT group spent significantly more time with healthcare professionals. It is difficult to distinguish whether the improvement was specifically due to CBT techniques or simply the result of increased clinical contact and support.

• No active control group (inflate effect size?)

• No participants who are referred for CBT because they don’t want to / can’t take antidepressants

• Didn’t contact ppts who completely withdrew from trial - different views to those who agreed to be interviewed?

• Small sample size

• Blinding issues

• TAU not standardised (could not control dosages or changes made over the research period) - dosage may increase over time, improving symptoms, leading to dropout

Nakagawa et al (2017) aim and method

• Aimed to determine if adding CBT to Treatment As Usual (TAU) would improve outcomes for patients with pharmacotherapy-resistant depression

• 80 outpatients aged 20–65 years who all met the DSM-IV criteria for Major Depressive Disorder.

• RCT followed 80 outpatients over 16 weeks, comparing those receiving both CBT and TAU against a control group receiving only TAU

Nakagawa et al. (2017) results

• CBT showed significantly greater improvement in depressive symptoms at 16 weeks vs medication-only

Nakagawa et al. (2017) evaluation

• No active control (sham group  / three arm RCT) - could inflate effect size. Is CBT working or is it the human interaction element

• Small sample size for RCT (though ppts number exceeded that required for power analysis)

• TAU was not standardised (medication management)

• Selection bias and potentially demand characteristics – unusually high retention rate (97.5%) suggesting motivated participants or 'best case scenario' - generalsiability

• Missing vulnerable population of severely depressed people

• influenced by therapist experience?

• no treatment control - nonspecific treatment effects e.g. patient expectations may also account for the observed efficacy of CBT.

Nakagawa et al. (2017) conclusions

supplementing medication management with CBT may be effective reducing depressive symptoms, improving treatment response and remission in patients with pharmacotherapy-resistant depression treated in psychiatric specialty care settings

beneficial effects at least medium-term (12 months at least)

need to replicate with larger sample size

Ijaz et al. (2018) aim and method

Review of efficacy of psychotherapies for adults 18-74 with treatment-resistant depression

6 trials, n=698 evaluating psychotherapy + usual care (antidepressants) vs usual care (with antidepressants)

3 = CBT added to usual care

1 each = intensive short‐term dynamic psychotherapy, interpersonal therapy, or group dialectical behavioural therapy

Ijaz et al. (2018) results

small sample sizes

high risk of detection bias (when groups differ in how outcomes are determined or verified) for main outcome of self-reported depressive symptoms

psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self‐reported depressive symptoms

Moderate‐quality evidence - psychotherapy + usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD.

Medium‐ and long‐term effects seem similarly beneficial, most evidence was derived from a single large trial.

Psychotherapy added to usual care seems as acceptable as usual care alone.

Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD.

No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regime - address this evidence gap

Siddique et al (2013) aims and method

• 1-year CT studies 267 low-income, young, minority women with MDD, comparing antidepressants, CBT, community referrals

siddique et al. (2013) results

• No sgnificant difference after 6 months, then superior after 12 months

• Among depressed women with moderate baseline depression and anxiety, medication was superior to CBT at 6 months, but the difference was not sustained at 1 year. Among women with severe depression, there was no significant treatment group difference at 6 months, but CBT was superior to medication at 1 year.

siddique et al. (2013) evaluation

• Very specific demographic

• Relatively small N

• Self-report - recall bias, social desirability

• Short-term follow-up - is 1 year enough to assess long-term results?

siddique et al. (2013) implications

• Socioeconomic factors - aetiological model

Cipriani et al. (2018) method

• Review of 522 trials, 116477 ppts with MDD

• antidepressant drugs vs. placebo, active treatments, head-to-head

What is a head-to-head trial??

compares two or more active treatments (tau?)

Cipriani et al. (2018) results

• All antidepressants more effective than placebo, some significantly more - but magnitude of overall benefits vs placebo modest

• All antidepressants associated w/ higher dropout rates (adverse effects) - significant between-drug variation

• Few differences between antidepressants when all data were considered

• More diversity in the range of efficacy and dropout patterns seen across the head-to-head comparisons than the meta-analysis of antidepressants versus placebo.

• Response to same antidepressant was on average smaller, dropouts more likely in placebo vs head-to-head trials

• Findings in adults contrast with the efficacy of antidepressants in children and adolescents, for which fluoxetine is probably the only antidepressant that might reduce depressive symptoms.

What is LOCF analysis?

Last Observation Carried Forward

The last observed non-missing value is used to fill in missing values at a later point in the study. Therefore one makes the assumption that the response remains constant at the last observed value.

Cipriani et al. (2018) evaluation

• Differential efficacy across age groups - heterogeneous mechanisms and causes of depression / smaller number of studies in young people / different methodological issues affecting adult and paediatric trials.

• More dropout in placebo trials because people think they have been allocated to placebo (effects take time) - so poorer responses than those remaining in treatment, carried forward to end of trial by LOCF analysis - underestimate drug efficacy?

• Effect sizes were smaller in more recent and larger placebo-controlled trials than in older and smaller ones - bias?

• Novelty effect - newer drugs appeared more effective than older ones

Pigitt et al. (2010) method

• This paper reviews four meta-analyses of FDA trials and analyzes STAR*D, the largest antidepressant effectiveness trial. Results show marginal efficacy compared to placebos and publication bias, suggesting a reappraisal of depression care standards.

• Limited statistical power - type 2 error

• Clinical heterogeneity of minor depression - different symptom profiles

• Dominant studies of paroxetine

• Not all antidepressants included

Pigitt et al. (2010) results

No statistically significant difference in treatment response between antidepressants and placebo for minor depression (or treatment discontinuation rates - a measure of acceptability)

Lots of publication bias inflates apparent efficacy

researchers fail to report the negative results for the prespecified primary outcome measure submitted to the FDA, while highlighting in published studies positive results from a secondary or even a new measure as though it was their primary measure of interest.

Effectiveness of antidepressant therapies was probably even lower than the modest one reported by the study authors with an apparent progressively increasing dropout rate across each study phase.

The reviewed findings argue for a reappraisal of the current recommended standard of care of depression

Zisook et al. (2011) method

• 665 outpatients with chronic/recurrent major depression

• comparing three antidepressant regimens over 28 weeks

Zisook et al. (2011) results

• All treatments significantly reduced suicidal ideation by week 4, 12, and 28. By week 28, 86% of those who started with SI no longer had it.

• 4 suicide attempts during the study, notably, all four occurred in the Venlafaxine XR + Mirtazapine group.

Zisook et al. (2011) evaluation

• An exploratory study – not RCT

• Single-blind (investigators knew the treatments)

• Patients at imminent risk of suicide were excluded (no high-risk patients)

• Baseline differences

Subsyndromal symptoms

symptoms falling below full DSM-V / ICD-10 criteria that may progess to full diagnosis

i have no clue what this has to do with pharmacological interventions tbh

efficacy issues of pharmacological interventions

there is conflicting evidence regarding the effectiveness of pharmacological interventions for mild depression, and risks of treatment resistance

long-term impact of pharmacological interventions

there is a risk of long-term dependency

unceratinty regarding whether medication actually addresses the root cause of depression

treatment resistance

some patients may be resistant to / experience adverse effects from medication

cost and stigma of pharmacological interventions

Significant financial burden and the weight of social stigma or perceived burden (Sher et al., 2005; Ilyas & Moncrieff, 2012; Cartwright et al., 2016).

common side effects of drug treatments

Agitation, nausea, dizziness, blurred vision, and sexual dysfunction (NHS, 2018).

risks of drug treatments

Treatment-worsening symptoms, including suicidal ideation during initial weeks (Zisook et al., 2009).

sub-group vulnerability

Elevated risk of self-harm and suicide attempts in specific populations (Nobile & Lopez-Castroman, 2017).