Misconceptions

Myths and the Effects

Media's Role

• • Entertainment and news media contribute to promoting the link between mental illness and violence.
  • Sensationalized portrayals reinforce stereotypes.

Importance of Education

• • Vital to inform and educate society about mental health.
  • Promote understanding and empathy for individuals with mental health conditions.

Historical Perspective on Abnormal Behavior

• • Early beliefs: Mental disorders were seen as possession by evil spirits, requiring expulsion.
  • 18th-19th centuries: Shift towards viewing mental illness as a physical disease.
  • Discovery of syphilis connection to delusions and personality changes supported physical perspective.
  • Condition of hysteria, prevalent in late 19th-early 20th centuries, viewed as rooted in psychological conflicts (Freud).
  • Mid-20th century: Some disorders attributed to faulty learning and thinking.

Modern Approaches

• • Diathesis-stress model proposes biological predisposition may be triggered by psychological stress.
  • Biopsychosocial perspective integrates biological, psychological, and social factors in understanding mental illness.
    • Example: Depression explained through genetics, faulty cognition, and lack of social support.

Study of Depression

• • Investigate interaction of biological, cognitive, and sociocultural approaches to diagnosis, etiology, and treatment.
  • Examine research methods and ethical considerations.

Factors Influencing Diagnosis

Professionals Involved:

• • Psychologists: Hold post-graduate degree in clinical psychology.
  • Psychiatrists: Trained as medical doctors, specialize in psychiatry.
  • DSM-5: diagnostic tool, published by the American Psychiatric Association, used by clinical practitioners to diagnose a wide assortment of recognized disorders, but is not universally accepted.

Different Approaches and Beliefs:

• • Abnormal Psychology → focuses on diagnosing, explaining, and treating individuals with psychological disorders.
  • Psychologists and psychiatrists may have varying opinions on the influence of biological, cognitive, and sociocultural factors.
  • Consensus generally agree that abnormal behavior is often influenced by an interaction of all three factors (biological, cognitive, and sociocultural).

Biological Approach:

• Focuses on the role of inheritance, brain structure and function, and animal research in understanding abnormal behavior.

Cognitive Approach:

• Focuses on faulty schemas, types of thinking, and beliefs (mental processes)
• Examines how social and cultural factors influence cognitive processes.

Sociocultural Approach:

• Focuses on social needs, cultural influences on defining normal and abnormal behavior.
• Explores how culture impacts behavior and the labeling process.

Normality Versus Abnormality

Abnormal Behavior

• • Includes disordering of emotions, thoughts, and behavior.
  • Diagnosing mental disorders is more complex than physical disorders.
  • Abnormal behavior defined based on its rarity in a population.
    • Rare behavior is labeled as 'abnormal'.
    • Example: Autism, occurring in 1% to 2% of children in certain regions.
    • Limitation:
      • Some rare behaviors may not indicate a mental disorder (e.g., speaking multiple languages).
      • Difficulty in determining the threshold for defining behavior as abnormal.
  • Abnormal behavior defined based on societal attitudes and unwritten rules.
    • Non-conformity to social expectations may lead to labeling as 'abnormal'.
  • Abnormal behavior defined as actions, moods, or thoughts that significantly impact an individual's well-being.
    • If a behavior makes life unbearable, it may be considered abnormal.
  • Challenges in Judgement → Determining when a person's behavior becomes dysfunctional can be difficult.
    • Example:
      • Heavy smoking or drinking, while self-harming and causing social and work-related difficulties, may not always be seen as abnormal by society.
  • Subjectivity of Perception → Individuals not functioning adequately may not perceive themselves as such.
  • Conditions like depression and phobias, which are prevalent, do not fit criterion of abnormal

Definition of 'Normal'

• • Relies on socially constructed and mutually agreed upon social and cultural norms.
  • 'Normal' behavior is not static and can change over time and across different cultures and societies.
    • Example: 19th Century Europe and USA:
      • Belief among psychiatrists that both physical and mental activity could be harmful to women.
      • Common diagnosis for women → 'hysteria', a broad term applied to many female patients.
        • 'Cure' for hysteria: Bed rest to prevent both physical and mental activity.

Controversy:

• • No consensus on what constitutes normality and abnormality.
  • Diagnosis sometimes is not always reliable or valid.
    • Ex: The DSM-5
      • Removal of a behavior from the manual doesn't necessarily mean it's considered normal across all cultures.

Cultural Considerations:

• • Cultural differences add complexity to diagnosing mental disorders.
  • Norms vary across different societies and cultures.

Cultural Internalization:

• Individuals internalize the norms of their own culture.
• Understanding norms of another culture can be challenging.
  • • Example:
      • Inability to learn to read due to a dysfunction in the corpus callosum may be considered a disorder in literate societies, but not in preliterate societies.

Ethical/Societal Considerations

• • Diagnosis of a mental disorder has profound consequences, raising important ethical considerations.
  • Danger → Risk of unfairly labeling individuals who do not conform to societal norms as deviant or threatening to society.
    • Historical Example:
      • Mid to late 20th century, Eastern European governments labeled political activists as mentally ill and confined them to mental institutions.

Homosexuality and Transsexuality

• • Societal attitudes towards these identities vary widely.
  • In some places, such behavior is illegal and punishable, while in others, there is increased tolerance.
  • In 1973, homosexuality was removed from the DSM-II classification of mental disorders.
    • 'Sexual Orientation Disturbance' replaced homosexuality as a category, reflecting a compromise between different views.
  • Current Approach → The DSM-5 uses the classification of Gender Identity Disorder for transgender individuals.
    • Introduces the term 'gender dysphoria' to denote distress over incongruence between experienced and assigned gender.

Szasz's Perspective on Mental Illness

• • Szasz (1960) argued that mental illness is a myth, proposing that many psychological disorders are better understood as 'problems in living'.
  • He criticized the medicalization of these issues and opposed the use of diagnostic systems like the DSM, which imply a medical disease.

Controversial Views

• • Szasz's notion that mental illness is a myth has generated controversy and has been criticized for going too far (Poulsen, 2012).
  • Despite controversy, Szasz's ideas continue to stimulate discussions on how to define normality and abnormality and to consider the ethical implications of diagnosis.

Wakefield's Model ('Harmful Dysfunction')

• • Proposed by Wakefield (2007) for categorizing behaviors as normal or abnormal.
  • Requires negative valuation by both the community and the individual (harmful) and a malfunction of an internal mechanism (dysfunction).

Challenge in Identifying Dysfunction

• • • Malfunctions of internal mechanisms (e.g., neurotransmitter issues) may not always be linked to abnormal behavior, posing challenges for diagnosis.
    • The implications of this model for treatment are not yet fully understood.

Deviation from “Ideal Mental Health”

• • Jahoda (1958) proposed a different approach to defining normality and abnormality.
  • Outlined characteristics that mentally healthy individuals should possess.
  • Seen as subjective, with cultural differences affecting how autonomy and independence are perceived.

Characteristics of Ideal Mental Health

• • • Positive attitude about oneself.
    • Pursuit of self-actualization, striving to be the best one can be.
    • Independence and self-reliance.
    • Coping ability with stress.
    • Adaptability to new situations.
    • Accurate perception of reality.

Positive Psychology

• • Developed by psychologists including Martin Seligman, focusing on positive emotions and character traits.
  • Aims to understand conditions that lead to lasting happiness and prevent mental health issues.

The Role of Cultural Clinical Biases in Diagnosis

Overview

• • Different cultures have varying criteria for defining normal and abnormal behavior.
  • They also have different ways of explaining abnormal behavior.
  • Culture-bound syndromes: Abnormal behaviors or disorders unique to specific cultures, not recognized outside of that society.
  • Mental health professionals may exhibit cultural blindness or rely on cultural stereotypes, leading to potential biases in diagnosis.
    • If a clinician is not familiar with a culture-specific syndrome, they may struggle with diagnosis and treatment, potentially leading to misdiagnosis and mistreatment.
  • Cultural differences affect how symptoms are reported or expressed may affect diagnosis.
    • Symptoms of mental disorders may vary across cultures, making diagnosis more complex.
    • Examples:
      • Amok or Mata Elap (Malaysia):
        • Characteristics:

Period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects.

Precipitated by a perceived insult.

Prevalent mostly among males.

Can be the first symptom of a serious mental disorder.

• • • • Shenjing Shuairuo (Chinese):
        • Equivalent to Neurasthenia:

Symptoms include physical and mental fatigue, dizziness, headaches, difficulty concentrating, sleep disturbance, and memory loss.

Additional symptoms: gastrointestinal problems, sexual dysfunction, irritability, excitability, and signs suggesting disturbances of the autonomic nervous system.

Similar to the Western diagnosis of major depressive disorder but often without lowered mood.

• • Reporting Bias: Data about a disorder gathered from hospital admissions may not accurately represent the prevalence of the disorder.
    • Factors:
      • Actual cases may not be properly diagnosed.
      • Some cultural groups may avoid seeking help from mental health care professionals.
      • Chinese patients may present with physical symptoms (Yeung and Kam, 2006).
      • Socioeconomic status may limit access to mental health care for certain ethnic groups (Tracy, 2017).

Cross-Cultural Variations in Symptoms:

• • • DSM-5 and ICD-10:
      • Symptoms listed in these manuals may not necessarily align with symptoms in ethnic minority groups.
        • Examples:

People from East Asia, especially China, may exhibit more somatic symptoms when depressed.

Black patients in the UK with bipolar disorder may report fewer suicidal thoughts and more manic episodes, potentially leading to misdiagnosis with schizophrenia (Kirov and Murray, 1999).

Study by Haroz et al. (2017):

Investigated cultural bias in the DSM-5 by reviewing qualitative studies on cultural differences in depression worldwide.

Argued that DSM-5 criteria and standard measuring scales/questionnaires are not culturally sensitive enough for cross-cultural depression diagnosis.

Studies

Study by Burr (2002) in the UK:

• Objective:
  • Investigated how cultural stereotypes of women from South Asian communities influenced mental health care professionals' explanations for suicide and depression patterns.
• Findings:
  • Low rates of treated depression and high rates of suicide in South Asian women in the UK.
  • Burr argued that these differences might be linked to stereotypes of 'repressive' South Asian cultures.
• Methodology:
  • Qualitative research using focus groups and individual interviews.
  • Participants were mental health carers from a UK inner-city area with high social deprivation.
  • Focus groups included mental health care professionals from inpatient and outpatient services.
  • Individual interviews were conducted with consultant psychiatrists and general medical doctors.
• Results:
  • Analysis of data suggested that health carers held cultural stereotypes.
  • South Asian culture perceived as repressive, patriarchal, and inferior to a Western cultural ideal.
• Impact:
  • Burr argued that these stereotypes had the potential to misdirect diagnosis, potentially affecting the mental health care provided to individuals from South Asian communities

Cross-Cultural Differences: Meta-Study by Tapsell and Mellsop (2007):

• • Aim:
    • Investigated the diagnosis and treatment of Mâori, the indigenous people of New Zealand.
    • Reviewed studies in terms of methodology, findings, and implications.
• Findings:
  • In some psychiatric settings, Maoris were more likely to present with hallucinations and aggression rather than depression and episodes of self-harm.
  • Studies in prisons and community-based samples reported that Mâori were less likely to access care.
  • When diagnosed with depression, Mâori were less likely to be prescribed antidepressant medication.
  • Rates of depression were significantly higher in Mâori women.
  • Mâori were overrepresented in those experiencing anxiety and substance misuse disorders.
• Conclusion:
  • Differences between Mâori and non-Mâori in New Zealand may reflect actual differences between ethnic and cultural groups.
  • Differences could also indicate inadequacies in non-Mâori healthcare workers, diagnostic tools, and services for Mâori patients.
  • Different cultures may perceive behaviors differently.
    • For example, seeing or hearing deceased relatives may be normal in some cultures but may be interpreted as symptoms of a psychological disorder in others.
  • Symptoms presented by Maori may be normal in their culture (e.g., seeing or hearing the deceased, mental withdrawal when feeling at a disadvantage).
    • Lack of cultural understanding among psychiatrists may lead to misinterpretation of these symptoms as signs of schizophrenia.
• Compare Example from New Zealand:
  • Studies in New Zealand highlight differences in defining mental health issues between Maori/Pacific Islanders and those from a European background.
  • Using DSM-IV, affective disorders accounted for 16% of diagnoses for Maori (compared to 30% for Europeans), while 60% of Maori diagnoses were for schizophrenia (compared to 40% for Europeans).

Validity and Reliability of Diagnosis

Diagnosis

• Valid Diagnosis: when a diagnosed person genuinely has a particular disorder as defined by diagnostic classification systems.
  • Establishing validity is challenging without using a diagnostic system, and these systems vary to some extent.
    • Example: The term "major depressive disorder" refers to a collection of symptoms that may vary between different diagnostic manuals.
  • Crucial when there are no biological diagnostic tests for the disorder.
  • Controversial Issue: How to differentiate between a normal response to a life event and the presence of a psychological disorder.
• Example - Depression and Bereavement:
  • In DSM-IV-TR (APA, 2000), depression after the loss of a loved one was diagnosed as major depressive disorder only if the depression persisted for longer than two months.
  • In DSM-5, the reference to bereavement has been withdrawn, raising concerns that grief and anxiety may be classified as mental illnesses.

Rosenhan's 1973 Study: "On Being Sane in Insane Places"

• • Aim:
• Determine whether the sane can be distinguished from the insane.
• Investigate if characteristics leading to diagnosis reside within patients or the environments and contexts in which observers find them.
• Methodology:
• Covert participant observation in 12 psychiatric hospitals across the U.S.
• Eight pseudopatients (including Rosenhan) attempted admission by complaining of hearing specific voices.
• Pseudopatients behaved normally once admitted.
• Four hospitals observed staff behavior toward patients.
• Follow-up study at a research hospital to see if the insane could be judged sane.
• Results:
• All pseudopatients, except one, were diagnosed with schizophrenia or manic-depressive psychosis.
• Hospital stays ranged from 7 to 52 days, with an average of 19 days.
• Pseudopatients were not detected by staff; fellow patients recognized their sanity.
• Staff behaviors included avoidance, lack of eye contact, and non-responsiveness.
• Follow-up study found 41 patients alleged to be pseudopatients, but there were none.
• Conclusions:
• Diagnostic process prone to errors; diagnosis influenced by environment.
• Once labeled, patients couldn't rid themselves of the diagnosis, impacting how they were treated.
• Psychiatric label has a life and influence of their own, affecting perceptions of behavior.
• Confirmation bias influenced diagnosis; behaviors confirming the diagnosis were attended to, while others were ignored.
• Enormous overlap in behaviors of the sane and insane.
• Psychiatric labels, even when invalid, are 'sticky,' influencing every aspect of a person's existence.
• Stigma of mental illness evident among hospital staff, affecting diagnosis, treatment, and care.

Face Validity in ADHD Diagnosis:

• Face validity is present when criteria seem to measure what they claim to measure.
  • Example - ADHD:
    • Good Face Validity:
      • ADHD (Attention-Deficit/Hyperactivity Disorder) is considered to have good face validity.
      • Criteria describe behaviors widely accepted cross-culturally as indicative of ADHD (Canino and Alegria, 2008).

Challenge with Clear Face Validity:

• • Social Desirability Bias:
    • Criteria with clear face validity are susceptible to social desirability bias.
    • Individuals may manipulate responses to downplay or conceal problems.
    • Exaggeration of behaviors might occur to align with the criteria.

Construct Validity in Diagnostic Testing:

• Construct Validity: assesses if a diagnostic test effectively supports the diagnosis by evaluating the relevance and accuracy of the questions asked.
  • Example - Beck's Depression Inventory (BDI-II):

Testing Construct Validity:

• • • • Psychologist Aaron Beck tested the construct validity of the Beck's Depression Inventory, version 2.
      • Used 210 psychiatric outpatients and compared BDI-II results with other diagnostic scales.
      • Found a high level of agreement, indicating that questions in the inventory were valid for diagnosing depression.

Biases in Clinical Judgment:

• • Identified Biases:
    • Pathology bias, confirmatory bias, hindsight bias, misestimation of covariance, decision heuristics, false consensus effect, and over-confidence in clinical judgment.
    • These biases can influence subjective judgments in diagnosis and treatment planning.

Repeated Measures and Bias Reduction:

• • Approach to Bias Reduction:
    • Taking repeated measures of symptoms, akin to the single-subject research design in behavioral sciences.
    • This approach aims to reduce judgment bias and enhance the accuracy of assessment and treatment.

Reliability in Diagnosis:

• Reliability: The accuracy or consistency of a diagnostic test.

Forms of Reliability:

Inter-Rater Reliability

• • Consistency in diagnoses when different mental health professionals assess the same patient using the same classification system.
    • Can be low due to overlapping symptoms in disorders (e.g., depression and anxiety).
    • Example: Two psychologists independently diagnose a patient with depression, demonstrating inter-rater reliability.

Test-Retest Reliability

• • Consistency of diagnoses over time, ensuring that a patient diagnosed with a certain disorder maintains that diagnosis if the condition persists.
    • Diagnostic labels can influence subsequent interpretations of behavior, making diagnoses appear 'sticky.'
    • Example: If a patient diagnosed with schizophrenia continues to exhibit symptoms, the same clinician should diagnose schizophrenia in the future, ensuring test-retest reliability.

Rosenhan Study Connection:

• If mental health staff had re-interviewed participants immediately after admission, consistent diagnoses should have led to discharges.
  • Diagnostic labels, once assigned, influence perceptions of subsequent behavior, creating a "sticky" effect.

Overlap with Cultural Considerations:

• Cultural factors play a significant role in ethical considerations related to diagnosis.
  • Example: Individuals not diagnosed, misdiagnosed, or mistreated due to cultural differences are subject to unethical treatment.

Stigmatization

• • Labeling individuals with mental health disorders may lead to social stigma, discrimination, and negative perceptions.
  • Ethical Concern → Stigmatization can impact individuals' lives, relationships, and opportunities unfairly.
    • Example: The stigma attached to certain mental health disorders affects how individuals are perceived and treated in society.

Self-Fulfilling Prophecy

• • Theexpectation of a certain outcome influences behavior, potentially leading individuals to fulfill the predicted behavior.
  • Ethical Concern: Diagnostic labels can become self-fulfilling prophecies, affecting individuals' perceptions of themselves and their actions.
    • Example: Once labeled with a mental health disorder, individuals may conform to societal expectations associated with that label.

Etiology of Abnormal Psychology

• Major Depressive Disorder (MDD)- is a complex mental health condition influenced by a combination of biological, psychological, and environmental factors.

Diathesis-Stress Model

• The idea that neurotransmitters play a crucial role in mood regulation emerged in the mid-1950s.
• Drugs affecting the release and breakdown of neurotransmitters, known as catecholamine or monoamine oxidase (MAO) transmitters, were found to have varying effects on mood.
• The model proposes that individuals have a biological predisposition (diathesis) for MDD, and the manifestation of the disorder depends on the presence of stressors.
• Diathesis (Biological Component): biological predisposition or vulnerability to a particular mental disorder.
  • In the context of MDD, the diathesis may involve genetic factors, such as an inherited predisposition for depression.
  • Studies on identical twins often show a higher correlation for MDD, indicating a genetic influence.
• Stress (Environmental Component): represents environmental factors or life events that can act as triggers for the development of a mental disorder.
  • In the case of MDD, stressors could include significant life events, chronic stress, or traumatic experiences.
  • The diathesis alone may not lead to MDD; it interacts with stressors to increase the likelihood of the disorder.
• The diathesis and stress components interact, influencing the likelihood and severity of MDD.
• Individuals with a higher genetic predisposition may require lower levels of stress to trigger MDD, while those with a lower diathesis may need more significant stressors.
  • • The model acknowledges individual differences in vulnerability and resilience.
    • Some individuals may have a strong diathesis, making them more susceptible to MDD, while others may have a weaker diathesis and require more substantial stressors.
    • The diathesis-stress model emphasizes a holistic understanding of mental disorders by considering biological, cognitive, and sociocultural factors.
    • It recognizes that the interplay of genetic and environmental influences contributes to the complexity of MDD.
    • The diathesis-stress model is a general framework applicable to various mental disorders, not limited to MDD.
    • It is used to explain the multifaceted nature of mental health conditions and how different factors contribute to their development.
• Chronic Illness: Some medical conditions, such as chronic pain or serious illnesses, may contribute to the development of depression.

Biological Factors

• • • Genetics: There is evidence of a genetic component in MDD. Individuals with a family history of depression are at a higher risk.
    • Neurotransmitter Imbalance: Alterations in neurotransmitters such as serotonin, norepinephrine, and dopamine play a role in mood regulation. Imbalances are associated with depressive symptoms.
    • Brain Structure: Changes in the structure and function of certain brain regions, including the amygdala, hippocampus, and prefrontal cortex, have been linked to MDD.

Psychological Factors

• • • Cognitive Vulnerability: Negative thought patterns, distorted thinking, and maladaptive cognitive processes contribute to the onset and persistence of depressive symptoms.
    • Personality Traits: Certain personality traits, such as high levels of neuroticism, pessimism, and low self-esteem, may increase susceptibility to MDD.
    • Psychosocial Stressors: Chronic stress, trauma, or adverse life events can trigger or exacerbate depressive episodes.

Environmental Factors:

• • • Early Life Experiences: Childhood adversity, abuse, or neglect may increase the risk of developing MDD later in life.
    • Social Support: Lack of a strong social support system or strained interpersonal relationships can contribute to the development of depressive symptoms.
    • Environmental Stressors: Financial difficulties, work-related stress, or major life changes can act as triggers for depressive episodes

Noradrenaline and Serotonin Hypotheses

• • • In 1965, Schildkraut proposed that depression might be associated with low levels of noradrenaline.
    • Subsequent research led to the hypothesis that serotonin, another neurotransmitter, was of particular interest in understanding depression (Coppen et al., 1967).

Antidepressant Medications:

• • • The neurotransmitter theory influenced the development of antidepressant drugs, including tricyclics, monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs).
    • SSRIs, such as fluoxetine (Prozac), became a major breakthrough, targeting the reuptake of serotonin and extending its activity in the synaptic gap.

Efficacy of Antidepressants:

• • • • The effectiveness of antidepressant drugs has supported the association between neurotransmitter levels and depression.
      • SSRIs, by preventing the reuptake of serotonin, have been successful in treating MDD.

Critiques and Complexities:

• • • The neurochemical theory, while influential, has faced critiques.
    • The short duration of neurotransmitter level changes compared to the delayed onset of antidepressant effects challenges the direct causation of depression by neurotransmitter deficiencies.
    • Lacasse and Leo argue against the idea of a baseline 'normal' serotonin level and caution against assuming causation based on the effectiveness of antidepressants (2005).
    • Levinson (2006) notes that a genetic factor, the short allele on the 5-HTT gene, affects serotonin reuptake similarly to Prozac but is associated with a higher risk of depression.

Need for Further Research

• • Despite advancements, there is a need for more in-depth investigation into the neurochemical aspects of depression.
  • Questions about the precise relationship between neurotransmitter levels, genetics, and depression remain, highlighting the complexity of the disorder.

Foundations of Cognitive Approach

• • According to the cognitive model, thoughts and beliefs play a crucial role in shaping behavior and emotions.
  • Psychological distress is viewed as dependent on an individual's cognitive processes, including schemas, cognitive structures, and assumptions.

Aaron Beck's Contribution:

• • Aaron Beck, a prominent psychologist, proposed that depression arises when individuals make attributions for external events based on maladaptive beliefs and attitudes.
  • Beck argued that at every level of depression, there is a deviation from logical and realistic thinking.
  • Depressed individuals exhibit themes such as low self-evaluation, ideas of deprivation, exaggeration of problems, self-criticism, self-command, and thoughts of escape or death.

Cognitive Vulnerability

• • Cognitive vulnerability is considered a high-risk factor for depression.
  • Three key concepts contribute to cognitive vulnerability: the cognitive triad, schemas, and cognitive errors.

Cognitive Triad

• • • A negative view of oneself, the world, and the future characterizes the cognitive triad in depression.
    • Negative view of the self: Depressed individuals perceive themselves as deficient, inadequate, and unworthy.
    • Negative view of the world: Interactions and life experiences are seen as difficult or hopeless, emphasizing defeats and failures.
    • Negative view of the future: Current difficulties are viewed as continuing indefinitely, leading to a sense of despair and hopelessness.

Schemas

• • • patterns of maladaptive thoughts and beliefs that become activated, particularly during stressful circumstances.
    • These maladaptive beliefs influence how individuals interpret the world, assigning positive or negative meaning to events.

Cognitive Errors:

• • • involve faulty thinking accompanied by negative and unrealistic representations of reality.

Hormonal Changes and Sociocultural Influences

• • While biological factors such as hormonal changes are considered triggers for depression, sociocultural psychologists argue that the social context, including gender expectations, interacts with these biological factors.
  • Adolescence and Gender Role Expectations:
    • Sociocultural factors, including societal expectations and gender roles, may contribute to depression during adolescence.
    • Social pressures on females to internalize feelings of anger and conform to traditional gender roles may contribute to the development of depression.
    • Gender Disparities:
      • Girls and women are reported to be diagnosed with MDD at a higher rate than boys and men.
      • Sociocultural psychologists argue that gender-related factors, such as societal restrictions and devaluation of women, contribute to the increased prevalence of depression in females.
  • Economic and Social Disparities:
    • Poverty and social isolation are identified as sociocultural factors influencing MDD.
    • Men in economically and socially disadvantaged groups are reported to be more likely to experience depressive symptoms compared to wealthier individuals.
  • Cross-Cultural Variations:
    • Sociocultural factors influencing depression may vary across cultures.
    • Studies in different countries, such as Poland, Russia, and the Czech Republic, highlight the impact of economic and social factors on the prevalence of depressive symptoms.

Prevalence Rates of Depression

• Prevalence Rates:
  • Overall global prevalence of MDD in 2015 was 4.4%.
  • Depression was more common among females (5.1%) than males (3.6%).
• Age Variation:
  • Prevalence rates varied by age, with peaks in older adulthood.
  • Among females aged 55-74 years, the prevalence was above 7.5%, and among males, it was above 5.5%.
• Trend Over Time:
  • The total estimated number of people living with depression increased by 18.4% between 2005 and 2015.
• Biological Factors:
  • Biological factors, including differences in hormones and genes, contribute to gender differences in depression.
• Cognitive Factors:
  • Cognitive factors play a role, with women being more prone to lowered mood and guilt.
• Sociocultural Factors:
  • Sociocultural factors influencing gender differences include:
    • Women being more likely to seek medical help when feeling depressed.
    • Male doctors, influenced by stereotypical beliefs about women, being more likely to diagnose them as depressed.
    • Women being more isolated than men, often due to caregiving responsibilities.
  • Culture Blindness:
    • Failure to consider cultural nuances may result in culture blindness, where the impact of culture on the expression and recognition of depression is overlooked.
  • Reporting Bias:
    • Cultural differences in stigma, attitudes toward mental health, and reporting practices can lead to bias in self-reported data. Some cultures may be more reluctant to acknowledge or report mental health concerns.
  • Cross-Cultural Variation in Symptoms:
    • Symptoms and expressions of depression can vary across cultures. Some cultures may emphasize physical symptoms over emotional ones, and certain emotional expressions may be considered culturally inappropriate.
  • Help-Seeking Behavior:
    • Cultural norms influence help-seeking behavior. Some cultures may encourage seeking professional help for mental health issues, while others may rely more on informal support systems or traditional healing practices.
  • Diagnostic Criteria:
    • The diagnostic criteria for depression are based on Western perspectives, and cultural variations may lead to differences in how symptoms are interpreted and reported.
  • Cultural Competence in Diagnosis:
    • Healthcare professionals need cultural competence to accurately diagnose and treat depression across diverse populations. Cultural sensitivity is essential to understanding the cultural context of an individual's experience.

Treatment of Disorders

Drug Categories:

• • Two older groups of antidepressants are tricyclics and MAO (Monoamine Oxidase) inhibitors. While effective, they often have troublesome side effects and can be lethal if misused.
  • Selective Serotonin Reuptake Inhibitors (SSRIs), such as fluoxetine (Prozac), are newer antidepressants that have become popular due to their effectiveness and generally milder side effects.

Limitations of Drug Therapy:

• • Drug therapy is criticized for treating symptoms rather than curing the disorder. Patients often need to continue medication to maintain the therapeutic effect.
  • Many antidepressants have significant side effects, although they are generally considered safer than earlier drugs that were associated with a risk of suicide.

Assessing Effectiveness:

• • Assessing the effectiveness of antidepressant medication is challenging
  • it's difficult to determine the course of MDD without medication
  • Placebo-controlled trials are one method

Emerging Treatments:

• • Ketamine, an anesthetic and a street drug known as "Special K," has shown promise in rapidly alleviating depression. It acts on different neurotransmitter receptors (glutamate) than traditional antidepressants.
  • Ketamine's quick action is notable, as many standard antidepressants may take weeks to show an effect. However, ketamine can have hallucinogenic effects and affects parts of the brain not directly related to depression.
  • While new treatments like ketamine show promise, challenges exist, such as potential side effects and suitability for all patients.
  • Ongoing research aims to identify safer and more effective biological interventions for MDD.

Electroconvulsive Therapy (ECT)

• • a psychiatric treatment that involves the administration of a short electrical stimulus to the brain through electrodes placed on the temples.

Procedure:

• • • The patient is anesthetized to induce unconsciousness during the procedure.
    • A muscle relaxant is administered to prevent convulsions from spreading to the rest of the body.
    • Tiny electrodes are placed on the temples, and a brief electrical charge is delivered to induce a controlled, therapeutic seizure.
    • The entire procedure typically lasts for a few seconds.

Treatment Sessions:

• • • ECT is usually administered in a series of sessions, with one electrical charge per day.
    • A common treatment schedule involves two or three sessions per week.
    • The entire course of treatment may consist of six to twelve sessions.

Indications for Use:

• • • ECT is often considered when other treatments, such as medication, have not been effective, especially in cases of severe depression or treatment-resistant Major Depressive Disorder (MDD).

Immediate Antidepressant Effect:

• • • Some research, such as the findings by Lapidus et al. (2013), suggests that a low-dose ECT treatment targeting the right side of the brain can have an immediate antidepressant effect.
    • Higher repeat doses may not be necessary in some cases.

Combination with Other Treatments:

• • • Both medications and ECT can be more effective when combined with psychotherapy.
    • The integration of multiple treatment modalities is often referred to as a multimodal or comprehensive treatment approach.

Side Effects and Risks:

• • • ECT is generally considered safe, but it can have side effects, including short-term memory loss and confusion immediately following the treatment.
    • The risk of more serious side effects is minimized through careful monitoring and the use of anesthetics and muscle relaxants.

Neuronal and Synaptic Changes in MDD:

• • Researchers conducted a meta-analysis of clinical studies that revealed associations between depression and reduced size in brain regions crucial for mood and cognition, specifically the prefrontal cortex and the hippocampus.
  • Additionally, decreased neuronal synapses were observed in these areas, indicating structural alterations at the synaptic level.

Antidepressant Effects on Neuronal Deficits:

• • • The study highlighted that traditional antidepressants can block or reverse the neuronal deficits observed in MDD.
    • However, these antidepressants are noted to have limited efficacy and often require weeks to months to show a therapeutic response.

Ketamine's Rapid Antidepressant Response:

• • • A significant aspect of the research is the observation that ketamine, an anesthetic and street drug, produces rapid antidepressant responses within hours, a notable contrast to the delayed response times of traditional antidepressants.
    • Ketamine's effectiveness is particularly noteworthy in patients who are resistant to typical antidepressants.
      • Basic studies discussed in the research indicate that ketamine rapidly induces action at the synaptic gap, potentially influencing neurotransmission.
      • Ketamine is reported to reverse synaptic deficits caused by chronic stress, offering a potential explanation for its rapid antidepressant effects.

Psychological Treatments of Depression

Cognitive-Behavioral Therapy (CBT)

• Developed by Aaron T. Beck, is a widely used and effective therapeutic approach for treating depression and various mental health conditions.
• Most common psychological treatment for Major Depressive Disorder
• CBT encompasses various specific treatment approaches, incorporating both cognitive and behavioral strategies.
• The term "cognitive-behavioral" indicates the integration of techniques that address both cognitive (thought-related) and behavioral aspects.

Definition and Techniques

• CBGT utilizes the group format in addition to common cognitive-behavioral therapy techniques to bring about changes in individuals' cognitive and behavioral patterns (Bieling et al., 2006).
• A key component of CBT is educating the client about the concept of faulty thinking.
• Clients learn to recognize and challenge negative thought patterns, gaining insight into the impact of these thoughts on their behavior and emotional well-being.

Emphasis on Core Psychological Beliefs

• Beck emphasized the importance of understanding and changing core psychological beliefs as a central aspect of treating depression.
• Core beliefs often involve negative thinking patterns and distorted perceptions of oneself, experiences, and the environment.

Restructuring Negative Thinking

• The core of CBT involves restructuring negative thinking. This process aims to challenge and change irrational or dysfunctional thought patterns that contribute to depressive feelings.
• By modifying these negative thoughts, positive changes can be achieved in the client's emotional and behavioral responses.
• CBT involves generating new, more adaptive ideas and ways of thinking to cultivate a positive outlook on oneself, experiences, and the surrounding environment.
• The goal is to replace negative thought patterns with more constructive and positive ones.

Role of the Therapist:

• • • The therapist plays a crucial role in CBT by actively engaging the client in the therapeutic process.
    • Beck and Weishaar (1989) emphasize that the therapist's role in CBT is to assist clients in examining alternative interpretations and providing contradictory evidence.
    • The therapeutic process aims to facilitate cognitive restructuring, wherein clients revise and replace faulty thoughts and beliefs.
    • Collaboration between the therapist and client involves setting realistic goals and taking responsibility for actions and thoughts.

Home Assignments:

• • • • Therapists often assign homework to reinforce and apply what is learned during therapy sessions.
      • Home assignments may include activities that help the individual review and understand the impact of faulty thinking on their behavior and emotional well-being.

Changing Thought and Perception:

• • CBT posits that changing thought and perception can lead to changes in behavior and emotional responses.
  • The therapy focuses on identifying and altering negative thought patterns that contribute to depression
  • Importance of Thoughts → The phrase "It is the thought that counts" underscores the significance of cognitive processes in influencing emotions and behavior.
    • By addressing and modifying negative thought patterns, CBT aims to bring about positive changes in emotional states.
      • Addressing Faulty Thoughts → The focus of CBT is to help individuals recognize and challenge faulty interpretations and conclusions that contribute to their depressive feelings.
        • Clients are encouraged to treat their faulty interpretations as testable hypotheses, allowing for an examination of alternative interpretations and the production of contradictory evidence.

Education and Awareness:

• • • A key component of CBT is educating the client about the concept of faulty thinking.
    • Clients learn to recognize and challenge negative thought patterns, gaining insight into the impact of these thoughts on their behavior and emotional well-being.

Specific Approaches in Depression:

• • • In the context of depression, CBT includes cognitive restructuring and the behavioral strategy of activity scheduling or behavioral activation.
    • Cognitive restructuring involves addressing and modifying negative thoughts underlying depression.
  • Effectiveness in Different Settings → CBGT has been shown to be effective in various settings, including residential and outpatient clinics.
    • Hunter et al. (2012) demonstrated the effectiveness of CBGT in treating major depression in clients undergoing residential substance abuse treatment. The results included a decrease in symptoms of depression and substance abuse after discharge.

Group Dynamics and Engagement

• • The theory behind group therapy for Major Depressive Disorder (MDD) is that individuals may feel more compelled to engage in group discussions than they would in individual therapy sessions.
    • Group members can benefit from hearing about the experiences of others facing similar challenges, fostering a sense of connection and shared understanding.
    • Group therapy provides an opportunity for participants to learn from the experiences of others in similar circumstances.
      • Observing and interacting with individuals who have successfully recovered or improved can instill hope in group members about their own potential for positive change.

Eclectic Approach

• • An eclectic approach involves combining two or more therapeutic techniques to tailor the treatment to the individual or group's specific needs.
  • Common Combinations → Half of all therapists describe themselves as taking an eclectic approach, and the most common combination is drug therapy and Cognitive-Behavioral Therapy (CBT).

Types of Eclectic Approaches

• • • Simultaneous use involves employing multiple therapies at the same time.
    • Sequential use is when one therapy follows another.
    • Stage-oriented use employs one therapy at a critical stage and introduces others at the maintenance stage.

Advantages of Eclectic Approach (Lebow, 2002)

• • • Broader theoretical base, potentially more sophisticated than a single-theory approach.
    • Greater flexibility to meet individual therapy needs.
    • Increased chances of finding an effective treatment with multiple approaches.
    • Suitable for a wider range of clients.
    • Objective and adaptable approach for therapists.
    • The therapist can revise and rebalance treatment based on effectiveness.

Considerations and Warnings (Lebow, 2002)

• • • The eclectic approach should not be confused with a lack of clear treatment ideas or applied inconsistently.
    • It may be too complex for a single therapist to undertake.
    • All treatments, eclectic or not, should be supported by evidence from previous studies.

Drug/Psychotherapy Combinations (Petersen et al., 2007)

• • • Combinations of drug and psychotherapy can be useful if combined in specific ways.
    • Recent research suggests that sequential administration of antidepressant and psychotherapeutic treatments may be more protective against relapse and recurrence than simultaneous treatment.

The Role of Culture in Treating Depression

Cultural Competence in Providing Therapy

• • Mental health professionals should be competent in providing therapy to individuals from various cultures.
  • Yeung and Kam (2006) emphasize that cultural differences can influence how individuals express and perceive symptoms of mental health issues, such as depression.
  • For example, their study indicates that Chinese clients may present depression differently than Americans or Europeans, with a higher proportion emphasizing physical symptoms over emotional ones.

Cultural Sensitivity in Therapy

• • Therapy itself should be sensitive to the culture of the client.
  • Therapists need to understand how cultural beliefs influence the presentation of symptoms and the acceptance of a diagnosis like depression.
  • Cultural competence is crucial in conducting culturally sensitive psychological evaluations.

Modifying Therapy Based on Culture (Gross, 2010)

• • Social roles within families, particularly in Asian cultures, are often well-defined and structured by age and sex. Understanding these dynamics is essential for effective therapy.
  • Therapy approaches emphasizing individual autonomy may clash with cultural values that prioritize family loyalties.
  • Cultural worldviews that attribute events to factors like fate or powerful others may require a different therapeutic approach than one that emphasizes personal responsibility.
  • Acknowledging spirituality is important in many cultures, and therapists need to recognize and respect the role of spirituality in the healing process.

Treatment Description:

• • OHDC is a culturally specific Cognitive-Behavioral Group Therapy (CBGT) designed for African Americans with depression.
  • The 12-week course involved 2.5-hour weekly sessions and was facilitated by African-American clinicians.
  • The course content included skills to cope with depression, incorporating African-American cultural beliefs and humanistic principles originating in Africa.
  • Topics covered in the course included anger management, forgiveness, and constructive thinking.

Research Design and Participants

• • Two pilots were conducted using a one-group pretest-posttest design.
  • Participants were recommended by local clinics and community groups in a suburban city in the Midwest of the USA.
  • Pilot I included 18 women with a mean age of 75, and Pilot II included 18 women and 17 men with a mean age of 51.

Outcome Measures

• • Participants completed psychological tests and surveys to measure depression, cognitive functioning, quality of life, physical health, and attitudes toward seeking mental health services.
  • Depression measures were administered before the course, after 6 and 12 weeks, and again 12 weeks after the end of the course.

Results

• • In Pilot I, there was a statistically significant decline in depression symptoms from pre- to post-intervention among the 73% of participants who completed the entire course.
  • In Pilot II, 66% of participants completed the full OHDC, and there was a significant decrease in depression symptoms for both men and women.
  • Participants reported satisfaction with the OHDC, but there was no change in attitudes toward seeking mental health services.

Conclusion and Future Directions

• • The investigators concluded that the findings were promising for a culturally adapted treatment for depression.
  • They emphasized the need for further research, particularly in large-scale, randomized control trials, to establish the efficacy of OHDC.

Assessing the Effectiveness of Treatments for Depression

Symptom Reduction

• • Primary strength → Effectively reduces symptoms of severe mental disorders.
  • Leads to significant improvement in mental health and overall functioning.

Complementary to Psychotherapy

• • Combining with psychotherapy enhances effectiveness.
  • Integration addresses both biological and psychological aspects (Cuijpers et al., 2010).

Quick Onset of Action

• • Some medications, like SSRIs, offer a relatively quick onset of action.
  • Crucial for alleviating acute symptoms and providing timely relief.

Improving Quality of Life

• • Successful treatment significantly enhances the overall quality of life.
  • Improvements in mood, cognition contribute to a better life.

Providing a Sense of Hope

• • Diagnosis and potential treatment instill hope.
  • Knowledge of treatment options contributes to a positive outlook.

Reducing the Risk of Relapse

• • Continuation of medication, as in MDD, decreases relapse risk.
  • Maintenance therapy sustains positive effects achieved during treatment.

Strengths of Individual Cognitive-Behavioral Therapy (CBT) for Major Depressive Disorder (MDD):

Client Empowerment:

• • Appeal of Control: CBT places control in the hands of the client, empowering them in the therapeutic process.
  • Active Participation: Clients actively engage in identifying and modifying maladaptive thoughts and behaviors.

Cognitive Focus:

• • Testable Cognitive Theories: Cognitive theories underlying CBT are testable, allowing for empirical evaluation.
  • Identification of Maladaptive Thoughts: Many individuals with psychological disorders, including MDD, display maladaptive assumptions and thoughts.

Effectiveness in Treating Mental Disorders:

• • Empirical Support: Studies, such as those by Beck et al. (1989), confirm the efficacy of CBT in treating mental disorders, especially depression, anxiety, and sexual disorders.
  • Well-established Approach: CBT is widely recognized and utilized for its effectiveness in addressing various mental health issues.

Rigorous Evaluation Criticism:

• • Critique of Rigor: Some studies confirming CBT efficacy have faced criticism for a perceived lack of rigor (Kramer, 2008).
  • Need for Robust Research: Continuous efforts are needed to ensure methodological rigor in evaluating the effectiveness of CBT.

Emotional Aspect Criticism:

• • Emphasis on Emotional Life: A persistent criticism is that CBT may not sufficiently emphasize a person’s emotional life.
  • Quick Fix Critique: Described by Rowe (2008) as a 'quick fix' that simplifies the complexity of emotional experiences underlying mental distress.

Simplicity vs. Depth Criticism:

• • Simplicity Critique: Criticized for oversimplifying the complexities of the emotional and psychological aspects of mental distress.
  • Assault on the Sense of Self Critique: Described as potentially minimizing the profound impact on the sense of self associated with mental distress.

Study on Cognitive-Behavioral Therapy (CBT) for Depressed Adolescents (Clarke et al., 1999):

Objective

• • Examine CBT Effectiveness: Investigate the effectiveness of CBT in treating major depression in adolescents.

Study Design:

• • Participants: 123 adolescents with major depression.
  • Random Assignment: Divided into three groups for an eight-week period: adolescent group CBT, adolescent group CBT with separate parent group, and control (waiting list).
  • Follow-up Period: Participants completing CBT groups reassigned to three conditions for a 24-month follow-up.

Interventions:

• • CBT Conditions:
    • Adolescent group CBT (16 two-hour sessions).
    • Adolescent group CBT with a separate parent group.
  • Control Condition:
    • Waiting list.

Follow-Up Conditions:

• • Participants from CBT groups reassigned to:
    • Assessments every four months with extra CBT booster sessions.
    • Assessments only every four months.
    • Assessments only every 12 months.

Booster Sessions:

• • Effect on Recurrence: Booster sessions did not reduce the rate of recurrence in the follow-up period.
  • Recovery Acceleration: Booster sessions appeared to accelerate recovery among participants still depressed at the end of the acute phase.

Outcomes:

• • Recovery Rates: CBT groups showed higher major depression recovery rates (66.7%) compared to the control group (48.1%).
  • Reduction in Depression: CBT groups exhibited a greater reduction in self-reported depression.
  • Adolescent-Only vs. Adolescent + Parent Conditions: No significant difference in outcomes between these conditions.
  • Lower Than Treated Adult Depression: Recurrence rates during the two-year follow-up were lower than those typically found in treated adult depression.