Depression

Depression

1. What is Depression?

   • A type of mood disorder
   • MAJOR DEPRESSION - UNIPOLAR DEPRESSION
     • Persistent depressive (Dysthymic) disorder
       • mild, lasts longer 20-30 years
     • Double Depression
   • BIPOLAR DISORDERS (formerly known as manic depression) - extreme
     • - Bipolar I disorder – major depression – full mania – 2 month cycle
     • - Bipolar II disorder – major depression – less mania
     • - cyclothymic disorder – mild depression/mania (long term)
   • OTHERS
     • SAD – Seasonal Affective Disorder (vitamin D deficiency)
     • Hypomania – less form of mania

2. Common Symptoms of Major Depression

   • Symptoms of depression span 5 areas of functioning
     • 1. Emotional - feel sad, miserable, empty, report deriving little pleasure from anything, may feel anxious
     • 2. Motivational - lack drive, initiative, spontaneity
     • 3. Behavioural symptoms - less active, less productive, sleep disturbed, changes in eating, move or speak more slowly
     • 4. Cognitive symptoms - depressed individuals often consider themselves inadequate, undesirable, inferior - also tendency towards pessimism, feel confused, indecisive, easily distracted
     • 5. Physical disturbances - headaches, indigestion, constipation, dizzy spells, general pain

3. How large a public health problem is depression?

   • Impact on Health system
   • Depression is the leading cause of non-fatal disease burden in Australia
   • WHO - By 2020 Depression will be the world’s second leading health problem

4. We all experience depression as a mood state from time to time - When does depression become a problem ?

   • 1. Whether the feelings are a normal reaction to loss and the duration and pervasiveness of depressive thought - do they extend beyond a time that is considered normal - difficult to determine
   • 2. Severity of depressed affect - inability to derive pleasure from usual activities - presence of suicidal thought
   • 3. Extent of disability associated with the condition- extent of disruption to normal functioning

5. Prevalence

   • Males - 3.4% VS Females - 6.8%
   • Lifetime prevalence
     • Females - 10-25% VS Males - 5-12%

6. Demographic characteristics related to depression

   • Age
     • women - used to peak late 40’s early 50’s - now younger
     • men - early 20’s, middle age, old age
     • overall increase in < 20’s - peak age for first incidence of depression
   • Socio Economic Status
     • lower SES more depression

7. Course of Depression

   • Period prior to depression
     • symptoms of major depression usually develop over days to weeks
   • How long does it last?
     • untreated cases up to 6 months or more treated cases - can control symptoms within 6-8 weeks in some instances

8. Can Depression be cured?

   • In majority of cases there is a full remission of symptoms - approx. 30 % of cases experience recurrent episodes

9. TREATMENTS

   • Psychological treatments
     • 1. Cognitive-Behavioural Approach
       • CB therapies - patient and therapist actively work together to develop more accurate beliefs and change behaviour
       • RET - replace irrational beliefs (“I am depressed because I am a failure - worthless”) with rational alternatives (“I might have failed in a few things lately, but that doesn’t make me worthless”)
       • Behavioural exercises (e.g pleasure predicting activity)
     • 2. Psychodynamic approach (Sigmund Freud)
       • depression is due to repressed sense of loss and unconscious anger turned inwards
       • since idea is to gain access to unconscious conflicts might use free association
     • 3. Humanistic Approach (Carl Rodgers)
       • - Person centered therapy
       • client takes lead - goal - main techniques - unconditional positive regard - empathy
     • Advantages
       • generally effective
       • can be as effective as use of antidepressant drugs
       • no side-effects, empowering
     • Disadvantages
       • will generally take longer than anti-depressants
       • a concern if person is suicidal
   • Biological treatments
     • Antidepressants
       • 1. MAO INHIBITORS
         • work by blocking the activity of an enzyme that can destroy serotonin and norepinephrine
       • 2. TRICYCLIC ANTIDEPRESSANTS
         • prevent reuptake of norepinephrine
       • 3. SEROTONIN REUPTAKE INHIBITORS
         • block reuptake of serotonin
     • Advantages
       • quick acting
       • within several weeks
     • Disadvantages
       • side effects
         • dryness of mouth, blurring of vision, constipation, palpitations, weight gain, sexual dysfunction, agitation, increased suicidal thought (Prozac)
     • Shock Treatment
       • can be extremely effective in cases of extreme depression
       • side effects (e.g memory loss)
       • patients are sedated, given muscle relaxant, shock delivered to non-dominant hemisphere only

10. Biological Factors

    • Neurochemical, transmitter models.
      • Changes in transmitters related to stress
      • Changes in structures in the brain associated with depression
      • Changes in hormones and inflammatory responses.
    • Sleep
      • Dysregulation of patterns
      • Neurobiological underpinnings different in depressed patients
      • Disturbance may precede onset or relapse- related to outcomes 

11. Cognitive Factors

    • Depressive schemas, maladaptive
      • beliefs/assumptions, negative automatic thoughts- emerge under stress – Diathesis stress model.
    • Depression associated with cognitive content related to themes of loss, deprivation, self depreciation, and hopelessness (as for example opposed to anxiety- themes of harm or threat)- although there is overlap between both disorders.
    •  Pessimism
    • Dispositional optimism-significant in psychological well being. Impacts on mood states during hardship (protective).
    • Optimism protective in lowering risk of depression in adolescents.
    • Optimism may play an important role in preventing depressive episodes after child birth.
    • Optimism buffers against ill health.

12. Social Factors

    • Beck (1967) referred to the risk for depression lying in the early experiences that develop a schema related to the negative triad (self, world and future)
    • Attachment and temperament.
    • Attachment or relationship with care giver exposes the individual to risk of developing negative cognitive schemas.
    • The insecure and disorganised attachment styles in childhood place the individual at most risk.
    • Other interpersonal processes
    • Reassurance seeking.
    • Interactional nature of depression.

13. Assessment

    • Risk Assessment
      • Risk Factors
        • Comorbid substance abuse
        • Severe depression, especially if psychotic or late onset
        • Medical Illness
        • Acts of deliberate self-harm
        • Recent stress,loss or situational crisis, family history of suicidal behaviour (esp. by hanging)
        • unemployment and/ or being“alone”
        • antisocial/aggressive behaviour,having a firearm
        • Behaviour which may be associated with increased risk
          • Numerous accidents
          • Dangerous and high risk behaviours
          • Discussing or writing about death and morbid themes
          • Giving away favourite possessions
      • History
        • Panic attacks and/or severe anxiety (psychological disorders)
        • Impulsivity
        • Biological basis
        • Family history of suicide
        • Recent/current stressors
          • Recent loss by death, divorce or separation
          • Single relationship status
          • Recent reduction in support
          • Severe hopelessness or helpness
            • Previous history of suicide attempts or threats to commit
            • Frequent suicidal ideation

14. Depression and Relationships

    • Interactional nature of depression
      • An attempt to explain the observations that individuals who are depressed have problems in their relationship interactions.
      • Early theories assumed that a depressed person had a negative cognitive bias which prevented them processing information related to positive aspects (relationship interactions) in their environment.
      • Coyne (1976) argued from a different perspective he suggested that the depressed person aroused negative reactions from others in their environment.
      • A negative cycle ensues where the depressed person seeks a high degree of reassurance from others and others offer non-genuine reassurance and support but then avoid the depressed person (this supports the depressed person’s views of others being unavailable and unsupportive and confirms their own negative views)
      • Individuals with negative reassurance seeking generate stress in interpersonal relationships and respond with a sense of urgency when they are trying to alleviate their own negative fears.
    • Self-verification theory
      • Self-verification theory describes a negative cycle within the depressed person’s relationships where they are unable to challenge their own negative view (and interact with others that support this view).
    • Interpersonal Psychtherapy
      • A time limited treatment program for individuals with unipolar depression.
      • Key concept is that life events occurring after early childhood years influence subsequent psychopathology.
      • IPT therapists assume etiology of depression multifaceted but use current or recent life events as the framework for treating the depressive episode (rather than past childhood events).
      • Stages
        • 1. Careful history of links between depressive symptoms and interpersonal problem areas.
          • Complicated bereavement, Role disputes, Role transitions, Interpersonal deficits (difficulties with social relationships, forming relationships etc.)
        • 2. Identify interventions focusing on problem areas identified.
        • 3. Maintenance and preparing for independence from treatment (e.g., planning ahead).