Depression

Depression

What is Depression?
1. A type of mood disorder
2. MAJOR DEPRESSION - UNIPOLAR DEPRESSION
  1. Persistent depressive (Dysthymic) disorder
    1. mild, lasts longer 20-30 years
  2. Double Depression
3. BIPOLAR DISORDERS (formerly known as manic depression) - extreme
  1. - Bipolar I disorder – major depression – full mania – 2 month cycle
  2. - Bipolar II disorder – major depression – less mania
  3. - cyclothymic disorder – mild depression/mania (long term)
4. OTHERS
  1. SAD – Seasonal Affective Disorder (vitamin D deficiency)
  2. Hypomania – less form of mania
Common Symptoms of Major Depression
1. Symptoms of depression span 5 areas of functioning
  1. 1. Emotional - feel sad, miserable, empty, report deriving little pleasure from anything, may feel anxious
  2. 2. Motivational - lack drive, initiative, spontaneity
  3. 3. Behavioural symptoms - less active, less productive, sleep disturbed, changes in eating, move or speak more slowly
  4. 4. Cognitive symptoms - depressed individuals often consider themselves inadequate, undesirable, inferior - also tendency towards pessimism, feel confused, indecisive, easily distracted
  5. 5. Physical disturbances - headaches, indigestion, constipation, dizzy spells, general pain
How large a public health problem is depression?
1. Impact on Health system
2. Depression is the leading cause of non-fatal disease burden in Australia
3. WHO - By 2020 Depression will be the world’s second leading health problem
We all experience depression as a mood state from time to time - When does depression become a problem ?
1. 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. 2. Severity of depressed affect - inability to derive pleasure from usual activities - presence of suicidal thought
3. 3. Extent of disability associated with the condition- extent of disruption to normal functioning
Prevalence
1. Males - 3.4% VS Females - 6.8%
2. Lifetime prevalence
  1. Females - 10-25% VS Males - 5-12%
Demographic characteristics related to depression
1. Age
  1. women - used to peak late 40’s early 50’s - now younger
  2. men - early 20’s, middle age, old age
  3. overall increase in < 20’s - peak age for first incidence of depression
2. Socio Economic Status
  1. lower SES more depression
Course of Depression
1. Period prior to depression
  1. symptoms of major depression usually develop over days to weeks
2. How long does it last?
  1. untreated cases up to 6 months or more treated cases - can control symptoms within 6-8 weeks in some instances
Can Depression be cured?
1. In majority of cases there is a full remission of symptoms - approx. 30 % of cases experience recurrent episodes
TREATMENTS
1. Psychological treatments
  1. 1. Cognitive-Behavioural Approach
    1. CB therapies - patient and therapist actively work together to develop more accurate beliefs and change behaviour
    2. 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”)
    3. Behavioural exercises (e.g pleasure predicting activity)
  2. 2. Psychodynamic approach (Sigmund Freud)
    1. depression is due to repressed sense of loss and unconscious anger turned inwards
    2. since idea is to gain access to unconscious conflicts might use free association
  3. 3. Humanistic Approach (Carl Rodgers)
    1. - Person centered therapy
    2. client takes lead - goal - main techniques - unconditional positive regard - empathy
  4. Advantages
    1. generally effective
    2. can be as effective as use of antidepressant drugs
    3. no side-effects, empowering
  5. Disadvantages
    1. will generally take longer than anti-depressants
    2. a concern if person is suicidal
2. Biological treatments
  1. Antidepressants
    1. 1. MAO INHIBITORS
      1. work by blocking the activity of an enzyme that can destroy serotonin and norepinephrine
    2. 2. TRICYCLIC ANTIDEPRESSANTS
      1. prevent reuptake of norepinephrine
    3. 3. SEROTONIN REUPTAKE INHIBITORS
      1. block reuptake of serotonin
  2. Advantages
    1. quick acting
    2. within several weeks
  3. Disadvantages
    1. side effects
      1. dryness of mouth, blurring of vision, constipation, palpitations, weight gain, sexual dysfunction, agitation, increased suicidal thought (Prozac)
  4. Shock Treatment
    1. can be extremely effective in cases of extreme depression
    2. side effects (e.g memory loss)
    3. patients are sedated, given muscle relaxant, shock delivered to non-dominant hemisphere only
Biological Factors
1. Neurochemical, transmitter models.
  1. Changes in transmitters related to stress
  2. Changes in structures in the brain associated with depression
  3. Changes in hormones and inflammatory responses.
2. Sleep
  1. Dysregulation of patterns
  2. Neurobiological underpinnings different in depressed patients
  3. Disturbance may precede onset or relapse- related to outcomes
Cognitive Factors
1. Depressive schemas, maladaptive
  1. beliefs/assumptions, negative automatic thoughts- emerge under stress – Diathesis stress model.
2. 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.
3.  Pessimism
4. Dispositional optimism-significant in psychological well being. Impacts on mood states during hardship (protective).
5. Optimism protective in lowering risk of depression in adolescents.
6. Optimism may play an important role in preventing depressive episodes after child birth.
7. Optimism buffers against ill health.
Social Factors
1. 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)
2. Attachment and temperament.
3. Attachment or relationship with care giver exposes the individual to risk of developing negative cognitive schemas.
4. The insecure and disorganised attachment styles in childhood place the individual at most risk.
5. Other interpersonal processes
6. Reassurance seeking.
7. Interactional nature of depression.
Assessment
1. Risk Assessment
  1. Risk Factors
    1. Comorbid substance abuse
    2. Severe depression, especially if psychotic or late onset
    3. Medical Illness
    4. Acts of deliberate self-harm
    5. Recent stress,loss or situational crisis, family history of suicidal behaviour (esp. by hanging)
    6. unemployment and/ or being“alone”
    7. antisocial/aggressive behaviour,having a firearm
    8. Behaviour which may be associated with increased risk
      1. Numerous accidents
      2. Dangerous and high risk behaviours
      3. Discussing or writing about death and morbid themes
      4. Giving away favourite possessions
  2. History
    1. Panic attacks and/or severe anxiety (psychological disorders)
    2. Impulsivity
    3. Biological basis
    4. Family history of suicide
    5. Recent/current stressors
      1. Recent loss by death, divorce or separation
      2. Single relationship status
      3. Recent reduction in support
      4. Severe hopelessness or helpness
        Previous history of suicide attempts or threats to commit
        Frequent suicidal ideation
Depression and Relationships
1. Interactional nature of depression
  1. An attempt to explain the observations that individuals who are depressed have problems in their relationship interactions.
  2. 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.
  3. Coyne (1976) argued from a different perspective he suggested that the depressed person aroused negative reactions from others in their environment.
  4. 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)
  5. 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.
2. Self-verification theory
  1. 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).
3. Interpersonal Psychtherapy
  1. A time limited treatment program for individuals with unipolar depression.
  2. Key concept is that life events occurring after early childhood years influence subsequent psychopathology.
  3. 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).
  4. Stages
    1. 1. Careful history of links between depressive symptoms and interpersonal problem areas.
      1. Complicated bereavement, Role disputes, Role transitions, Interpersonal deficits (difficulties with social relationships, forming relationships etc.)
    2. 2. Identify interventions focusing on problem areas identified.
    3. 3. Maintenance and preparing for independence from treatment (e.g., planning ahead).

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