Depressive Disorders

• Diagnostic Overview of Major Depressive Episode:

  • At least one of the following

    • Depressed mood: feeling of sadness, emptiness, or hopelessness

    • Lack of interest and feelings of pleasure: reduced capacity to experience pleasure(anhedonia). Depression isn’t just the presence of negative moods, but also the lack of positive moods

  • In addition to at least one core symptom(above), the individual must have 5 or more 

    • Disrupted sleep patterns: insomnia or hypersomnia

    • Changes in psychomotor functions:psychomotor agitation or psychomotor retardation

    • Changes in appetite

    • Inability to concentrate

    • Lack of energy

    • Feelings of guilt and lack of self-esteem

    • Desire to end one's life or suicidal ideation

  • Impact: symptoms must exceed cultural and contextual norms. Symptoms are related to clinically significant distress or create impairment in important areas of life such as with friends and family or work or school

  • Timeframe: at least 14 days in a row

• Diagnostic overview of dysthymic episode:

  • Depressed mood: a sad or down mood

  • At least three of the following:

    • Poor Or excessive appetite

    • Disrupted sleep patterns: problems getting to sleep or sleeping too much and not feeling rested

    • Lack of energy

    • Low self-esteem

    • Problems with concentration and decision-making

    • Feelings of hopelessness

  • Impact: symptoms must exceed cultural and contextual norms. Symptoms are related to clinically significant distress or create impairment in important areas of life such as with friends and family or at work or school

  • Time frame: at least 4 days in a row

• Diagnostic overview of persistent depressive disorder:

  • Either a major depressive episode or a dysthymic episode

  • Impact: symptoms must exceed cultural and contextual norms. Symptoms are related to clinically significant distress or create impairment in important areas of life such as with friends and family or at work or school

  • Timeframe: at least two years

• Diagnostic overview of prolonged grief disorder

  • After the death of someone close, a person experiences intense preoccupation or yearning for the deceased person. At least three of the following symptoms:

    • Identity disruption(feeling as if a part of them has died)

    • Disbelief about the death

    • Avoidance of any reminders that the person has died

    • Emotions;l pain related to the death

    • Difficulties in moving on

    • A feeling of emotional numbness

    • Loneliness as a result of the death

    • A sense that life is meaningless

  • Impact: symptoms must exceed cultural and contextual norms. Symptoms are related to clinically significant distress or create impairment in important areas of life such as with friends and family or at work or school

  • Timeframe: at least 1 month of symptoms that are 12 months after the death of someone close to them

• Psychological theories of depression

  • Psychodynamic model

  • Behavioral model

  • Cognitive model

  • Learned helplessness model

  • Hopelessness model

• Biological theories of depression

  • Brain circuitry

  • Neurotransmitter imbalance

  • Functional brain asymmetry

  • Role of neuroendocrine influences

• Depression and stressful life events

  • Stressful life events (SLEs) may trigger depressive episodes directly or may lead to de[ression through indirect mechanisms

  • Examples of SLEs:

    • Childhood adversity/trauma/abuse

    • Job loss

    • Interpersonal Loss(marriage failure, break up)

    • Death of a close friend or loved one

    • Change in the financial state

    • Change in health or health of family member 

    • Imprisonment

• Lewinsohn’s behavioral theory of depression

  • Stressor leads to reduction in reinforcing events/reinforcers->person withdraws->further reductions in reinforcing events/exposure to reinforcers->more withdrawal->more depression

    • Self-perpetuating cycle

• Behavioral view

  • Depression results from changes in rewards and punishments people receive in their lives

  •   Lewinsohn suggests that the positive rewards in life dwindle for some people, leading them to perform fewer and fewer constructive behaviors, and they spiral toward depression

  • Research supports the relationship between the number of rewards received and the presence or absence of depression

  • Social rewards are especially important

• Etiology of MDD: Cognitive Theories

  • Beck’s Theory

    • Negative schema: the underlying tendency to see the world negatively

    • Negative triad: negative view of self, world, future

    • Negative schema causes cognitive biases: the tendency to process information in negative ways

  • Helplessness theory

  • Hopelessness theory(a modification of Helplessness Theory)

    • Most important trigger of depression is hopelessness

      • Desirable outcomes will not occur

      • Person has no ability to change situation

    • Attributional style

      • Stable and global attributions can cause hopelessness

    • Rumination theory

      • A specific way of thinking: the tendency to repetitively dwell on sad thoughts

      • Most detrimental is to brood over the cause of events

  • 
    

• Seligman’s learned helplessness model of depression

  • Depression results from being in aversive situations in which one has no control over the outcome

  • Seligman focused on three attributional dimensions:

    • internal/external

    • global/specific

    • stable/unstable

  • The internal, global, and stable attributions are most likely to lead to depression

• Alloy and Abraks0n’s hopelessness model of depression

  • Cognitive diathesis-stress model

  • State of hopelessness + stressful life event ->depression

  • Hopelessness expectancy:

    • The person has no control over what is going to happen

    • An important bad outcome is going to occur or a highly desired good outcome is not going to occur

• Depression and Cortisol Dysregulation

  • The hypothalamic-pituitary-adrenal (HPA) axis is central to the body’s response to stress

  • The HPa axis, part of the hormonal system is implicated in depression

  • The HPA axis triggers the release of cortisol, the main stress hormone

  • Link depression to high cortisol levels

• How does stress cause depression

  • Inflammatory response

  • cytokines->proteins that are released as part of an immune response

  • Pro-inflammatory cytokines are part of the body’s way of fighting off infection, by triggering an inflammatory response

  • Research shows that inflammation may play a role in how stressful life events trigger symptoms because life stresses, especially interpersonal life stressors can lead to increases in proinflammatory cytokines

• Cognitive therapy for depression

  • Goal:to challenge and change the maladaptive automatic thoughts that contribute to depression

• Behavior therapy for depression

  • Goal: to encourage clients to avoid social isolation and restriction of activities that may be contributing to their depression

• Psychodynamic therapy for depression

  • Goal: to encourage clients to strengthen social relationships that provide personal satisfaction

• Melancholic Depression

  • Melancholic Depression

    • The most severe form of depression

    • Characteristic features

      • Decreased appetite

      • Early am awakening

      • Anhedonia

      • Diurnal variation

    • Better response to antidepressant medication and/or ECT

• Biological interventions for major depression

  • Antidepressant medication

    • Monoamine oxidase(MAO) inhibitors

    • Tricyclic antidepressants

    • Serotonin selective inhibitors(SSRIs)

    • Serotonin and norepinephrine reuptake inhibitors(SNRIs)

    • Noradrenergic and specific serotonergic antidepressants(NaSSAs)

  • Electroconvulsive Therapy(ECT)

  • Transcranial Magnetic Stimulation(TMS)

  • Phototherapy

  • Vagus Nerve Stimulation

  • Deep Brain Stimulation

• Treatment Options for Depressive Episodes

  • Antidepressants

    • Tricyclic antidepressants

    • MAO(monoamine oxidase) inhibitors, and 

    • Second-generation antidepressants, including SSRIs, SNRIs

  • Psychotherapy, esp cognitive-behavioral 

  • Electroconvulsive therapy

  • Phototherapy

  • Transcranial magnetic stimulation(TMS)

  • Vagus nerve stimulation 

  • Deep brain stimulation(experimental)

• Transcranial magnetic stimulation

  • Relatively experimental technique

  • Uses magnetic field changes to induce current

  • Indirect electric stimulation

  • Much lower energy is required to change neuronal activity

  • The magnetic field can be highly focused

  • Reportedly fewer cognitive side effects

• Electroconvulsive therapy

  • Established technique

  • Uses electric current to change cortical activity

  • Direct electric stimulation of CNS

  • Very large currents needed to change neuronal activity

  • More widespread passage of current through the cortex

  • More cognitive side effects

• Options for treatment-resistant depression

  • ECT as an add-on

  • Vagus nerve stimulation

  • Ketamine as an add-on

    • NMDA receptor(Glutamate receptor)

  • Deep brain stimulation

• Deep brain stimulation-experimental alteration

  • (for medically intractable Major depression)

  • How it works:

    • An invasive medical procedure that was originally intended for the treatment of Parkinson’s Disorder, this is now being tried for medically intractable major depression

Depressive Disorders

What are the different types of depressive disorder?

What are the different etiological models of depression?

What are treatment options for depression?

What are the four types of symptoms for a major

Depressive episode? Can you identify them?

What neurotransmitter(s) are implicated in depressive disorders?

What are the disadvantages and advantages of the treatments for depression?