Depression

Page 1: Introduction to Depressive Disorders

• Title: Depressive Disorders

• Source: Castonguay CH. 2

Page 2: Major Depressive Disorder

• Definition: Major Depressive Episode characterized by 5 or more symptoms, including:

  • 1. Depressed mood (sad, down, blue)

  • 2. Anhedonia (reduced interest/pleasure)

  • 3. Appetite disturbance

  • 4. Sleep disturbance

  • 5. Feelings of worthlessness or inappropriate guilt

  • 6. Loss of energy/fatigue

  • 7. Difficulty concentrating or indecision

  • 8. Psychomotor agitation or retardation

  • 9. Recurrent thoughts of death or suicide

• Duration: Symptoms must last for at least two weeks and occur for most of the day, not better explained by another medical condition or substance use.

• Impact: Must cause clinically significant distress or impairment, distinct from normative responses to loss.

Page 3: Symptoms/Measures of Depression

• Beck Depression Inventory-2nd Edition

  • Item on loss of energy:

    • 0: I have as much energy as ever.

    • 1: I have less energy than I used to have.

    • 2: I don’t have enough energy to do very much.

    • 3: I don’t have enough energy to do anything.

• Hamilton Rating Scale for Depression:

  • Item on changes in sleeping pattern:

    • 0: No change in sleep pattern

    • 1: Sleep somewhat more than usual

    • 2: Sleep somewhat less than usual

    • ...

  • Depressed Mood Scale:

    • 0: Absent

    • 1: Gloomy attitude, pessimism

    • 2: Occasional weeping

    • 3: Frequent weeping

    • 4: Predominantly those feelings in communication.

Page 4: Behavioral Observation in Depression

• Self-report method focusing on:

  • Changes in functioning

  • Onset and course

  • Severity of symptoms

  • Degree of functional impairment

• Questioned: What are the etiology behind depressive symptoms?

Page 5: Persistent Depressive Disorder

• Definition: Minimum duration of 2 years with:

  • Depressed mood and at least 2 additional symptoms of depression.

  • Symptoms must be present at least half of the time.

• Note: Replaces ‘Dysthymia’ from DSM-IV, representing a more chronic form of MDD.

Page 6: Prevalence of Depressive Disorders

• Major Depressive Disorder (MDD):

  • Lifetime prevalence is estimated at 12-16% in the U.S.

  • Point prevalence: ~8% at any given time.

• Gender Ratio: Women to Men is approximately 2:1.

• Persistent Depressive Disorder prevalence yet unknown (new category).

• Former Dysthymic Disorder had a prevalence of about 2.5% lifetime.

• Cohort effect: Increasing rates of depression in succeeding generations.

Page 7: Comorbidities in Depression

• Approximately 60% of individuals with MDD also meet criteria for Anxiety Disorders.

• Additionally often comorbid with:

  • Substance use disorders

  • Personality disorders

• Speculated shared underlying mechanisms.

Page 8: Causes of Depression

• Heritability: Estimated at 37% for MDD; higher for severe cases.

• Neurobiological factors:

  • Low levels of serotonin

  • Reduced sensitivity in serotonin receptors

  • Insensitive dopamine receptors.

• Critique: "Chemical Imbalance" theory faces challenges due to insufficient evidence.

Page 9: Chemical Imbalance Theory Critique

• Deacon (2014): Mental disorders seen as brain diseases from neurotransmitter dysregulation, genetic factors, structural brain defects.

• Lack of identified biological cause or reliable biomarkers for any mental disorder.

• Claims about psychotropic medications correcting neurotransmitter imbalances lack credible evidence.

Page 10: Psychosocial Factors in MDD

• Key factors contributing to MDD include:

  • Life stressors

  • Interpersonal difficulties

  • Reduction in reinforcement

  • Negative cognitions:

    • Attentional biases: Tendency to focus on negative stimuli (sad, angry).

    • Dysfunctional thoughts: Rumination, negative attributional style attributing negative events internally, globally, and stably.

Page 11: Beck’s Cognitive Model of Depression

• Early experiences may lead to dysfunctional assumptions affecting vulnerability to depression.

• Critical incidents can trigger these assumptions, causing negative automatic thoughts which produce symptoms of depression, further fueling those thoughts.

Page 12: Interactive Model of Depression

• Components involved:

  • Emotions

  • Cognitions

  • Behaviors

  • Neurobiological factors

Page 13: Treatment for Depressive Disorders

• Various medications include:

  • SSRIs (Selective Serotonin Reuptake Inhibitors)

  • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

  • MAOIs (Monoamine Oxidase Inhibitors)

• Irving Kirsch’s studies show effect sizes of antidepressants and placebos.

  • Antidepressants: High effect size (1.6)

  • Placebo: Effect size of 1.2

  • No-treatment controls: 0.37 (indicating natural improvement).

  • A significant portion of improvements attributed to expectancy effects and natural recovery.

• Concerns expressed about selective publication bias affecting reported efficacy.

Page 14: Mean Improvement in Drug vs. Placebo

• Summary of key findings regarding improvement in specific drug and placebo conditions across trials:

  • Fluoxetine: Drug: 8.30; Placebo: 7.34; Proportion: 0.89

  • Paroxetine: Drug: 9.88; Placebo: 6.67; Proportion: 0.68

  • Sertraline: Drug: 9.96; Placebo: 7.93; Proportion: 0.80

  • Others include Venlafaxine, Citalopram displaying similar trends.

Page 15: Selective Publication of Antidepressant Trials

• Investigation of discrepancies between journal versions of antidepressant trials and FDA submissions.

• Results show inconsistencies that influence perceived efficacy of treatments.

Page 16: Biological Treatments for Depression

• Other biological approaches include:

  • Electroconvulsive Therapy (ECT)

  • Transcranial Magnetic Stimulation (TMS)

Page 17: Psychological Therapies

• Range of psychological therapies applied includes:

  • Interpersonal Therapy (IPT)

  • Cognitive Therapy (Cognitive-Behavioral Therapy)

  • Behavioral Therapy (Behavioral Activation)

  • Mindfulness-based approaches: Research indicates mindfulness training may outperform conventional methods for postpartum depression, though results can vary in real-world applications.

Page 18: Behavioral Methods

• Aim: Identify and change depressive behaviors.

• Techniques include:

  • Behavioral activation

  • Self-monitoring

  • Scheduling daily activities that bring pleasure or accomplishment.

  • Reducing avoidant behaviors.

Page 19: Behavioral Activation Techniques

• Self-monitoring example:

  • Identify activities and associated emotional ratings (e.g. watching TV, lying in bed).

  • Understand behaviors worsening mood vs. opportunities for improvement.

  • Schedule alternative, goal-directed behaviors.

Page 20: Activity Scheduling Recommendations

• Engaging in alternative activities instead of less beneficial ones:

  • Replacing TV time with reading, walks, or chores.

  • Planned meals with friends over eating convenience foods.

  • Regulated TV before bed to improve sleep quality.

Page 21: Targeting Psychological Factors in Treatment

• Cognitive approaches:

  • Objective: Modify distorted beliefs and thoughts.

  • Use thought records to capture and evaluate mood-related thoughts.

  • Benefits of combining CBT with medication noted.

Page 22: Cognitive Distortions

• Common cognitive distortions explained:

  1. All-or-Nothing Thinking: Black or white thinking.

  2. Fortune-Telling: Making negative predictions about the future.

  3. Labeling: Assigning negative labels to oneself.

  4. Emotional Reasoning: Believing feelings equate to reality.

  5. Selective Abstraction: Focusing only on negative details.

  6. Overgeneralization: Broad conclusions from limited evidence.

  7. Mind Reading: Assuming to know others' thoughts.

  8. Personalization and Blame: Taking events personally.

  9. Should Statements: Strict standards for oneself.

  10. Magnification/Minimization: Distorting the importance of events.

Page 23: Testing Beliefs

• Format to analyze cognitive distortions by addressing the situation, thoughts, emotions, and outcomes:

  • Record date, time, situation.

  • Capture automatic thoughts and associated emotions.

  • Weigh evidence for/against thoughts.

  • Determine alternative responses.

Page 24: Belief Evidence Analysis

• Example analysis for "I’m a failure":

  • Evidence for: N/A

  • Evidence against: Lots of friends appreciate me, employed since college, honest.

  • Belief level: 20% for; 80% against.