412 Depression

Question 1

core features of depression

Answer 1

• dysphoria (prolonged sadness)
• irritability (excessive sensitivity, hostility, moodiness)
• anhedonia (loss of pleasure or interest in previously enjoyable activities)

Question 2

symptom vs. syndrome vs. disorder

Answer 2

• symptom: feeling of emotion or sadness (common)
• syndrome: cluster of common symptoms (extreme on dimension of negative mood/affect)
• disorder: syndrome that has been occurring for a certain amount of time and occurring with impairment in functioning

Question 3

DMDD differential diagnosis

Answer 3

• cannot be diagnosed concurrently with ODD or Bipolar
• DMDD was created for kids who were being diagnosed with BP but only presenting with irritability
• DMDD is more chronic irritability, while BP is more phasic
• more intense irritability than you might see in MDD/PDD

Question 4

evidence for DMDD

Answer 4

• applying new criteria to existing data = hazy boundaries, not good at identifying those with the disorder
• DMDD not well differentiated from CD or ODD
• not much difference in symptom severity or functional impairment with or without the disorder
• DMDD diagnosis showed poor stability
• very high comorbidity (also meeting criteria for ODD, which can’t be diagnosed concurrently)
• validity is questionable, high risk of over-diagnosis (irritability is very common in child development)

Question 5

epidemiology of DMDD

Answer 5

• limited studies before DSM-5 inclusion showed highest rates of symptoms in preschoolers
• highest co-occurrence with depressive disorders and ODD (higher rates of social impairment, school suspension, service use, poverty)

Question 6

categorical vs. dimensional depression

Answer 6

• many kids and teens have subclinical depression
• still show significant impairment
• at greater risk for developing depression and other disorders/difficulties

Question 7

epidemiology of MDD

Answer 7

• 1% or preschool-age kids
• 2% of elementary-school kids
• 11% of adolescents
• racial ethnic differences: Latinx youth and Black youth more likely to experience mood disorders, but white youth more likely to receive Tx (lower SES, discrimination)
• lack of gender differences in childhood, and divergence increases after 15

Question 8

possible explanations for the gender gap

Answer 8

(1) girls more likely to seek help (gender difference found in community samples, but there isn’t necessarily a difference)
(2) biological factors (onset of gender disaprity emerges during puberty, earlier puberty = depression but only in girls, puberty may sensitize girls to stress)
(3) puberty may create stress for girls (changes in physical appearance, sex-role identification), especially interpersonal stress (peer rejection, conflict, generating stress) because girls are invested in their relationships
(4) cognition: negative attributions (but this appears to be equal for boys and girls)
(5) coping: girls tend to ruminate or co-ruminate

Question 9

preschool depression

Answer 9

• earlier onset associated with more severe and chronic depression later (and higher rates of ADHD and anxiety at school age)
• 2-week duration criteria not as relevant for preschoolers (even if not met, still associated with MDD 2 years later)
• depressed 4-6 year-olds show altered brain activity (more amygdala activity when viewing emotional faces, like you see in adults) - dirupted amygdala functioning could be a biomarker or a consequence of depression throughout lifetime

Question 10

biological factors

Answer 10

• high (but lots of variability) heritability estimates (35-75%)
• early exposure to stress can sensitize to later stress (stress reactivity)

Question 11

stress reactivity

Answer 11

• depression in moms associated with higher cortisol levels which can affect fetus
• number of months a woman is depressed is associated with child’s elevated cortisol levels at 6-7 years
• epigenetic transmission of biological processes
• transmission of altered stress physiology postnatal through breastmilk
• early experiences (sensitive period) with caregivers important for attachment (maternal depression may be associated with problematic parenting which alters child’s stress reactivity)

Question 12

social-cognitive processing in depression

Answer 12

• negative encoding biases (attentional, toward sadness/negative affect)
• interpretation (negative attributional biases, unconscious pattern of response)
• response search not as important, but still tend to identify fewer assertive responses
• response decision: report themselves as less able to carry out assertive strategies (and as less effective) and think avoidant strategies are better

Question 13

interpretation biases study

Answer 13

• looking at high-risk population (cognition as a risk factor)
• blending two words acoustically (neutral-negative, neutral-positive) to make the result a 50-50 chance of hearing either word
• at-risk girls showed a preference for depression-related negative words (but not threat words), control group showed a preference for positive words

Question 14

interpersonal theories of depression

Answer 14

• less prosocial, less assertive, more avoidant and withdrawn, kids may be more hostile and aggressive
• responding to interpersonal challenges in problematic ways
• difficult to maintain healthy and close friendships with depression (less support, less social skill training)

Question 15

stress exposure models of depression

Answer 15

• depression caused by exposure to stress
• peer rejection leads to depression

Question 16

stress generation models of depression

Answer 16

• higher depression leads to higher stress exposure
• symptoms impact your interactions, and those difficulties cause interpersonal problems which exacerbate symptoms
• depressed kids get rejected more

Question 17

evidence for stress generation models

Answer 17

• clinical interview to place participants into 4 groups: depressed only, externalizing only, both, control
• assessed life stress experiences and rated them in terms of severity, extent to which child contributed to the event (independent or dependent), interpersonal/non-interpersonal
• depression associated with dependent and interpersonal stress
• externalizing associated with dependent and non-interpersonal
• neither was associated with independent
• comorbid had highest levels of interpersonal and non-interpersonal

Question 18

co-rumination

Answer 18

• dwelling on problems without solving them with a friend
• associated with better friendships, but also with more negative mood
• dwelling on negative affect with a friend = negative mood, but not friendship quality
• rehashing the problem and speculating about what might happen = better friendship, but not negative mood

Question 19

reassurance seeking

Answer 19

• initially, friends are happy to provide reassurance, but people keep seeking because they think they don’t mean it
• over time, this becomes irritating and invalidating
• which leads to friendship withdrawal and peer rejection
• associated with unstable friendships

Question 20

contagion

Answer 20

• your own depressive symptoms predict your friend’s depressive symptoms
• co-rumination is the mediating mechanism

Question 21

CBT model of depression

Answer 21

• based on diathesis-stress model
• depression maintained through negative cognitive and behavioural processes
• target depressogenic thinking, low reinforcement and negative life events, skill deficits
• automatic thoughts and behavioural inhibition

Question 22

emotional spirals in depression (CBT)

Answer 22

• negative events breed negative moods = negative behaviours = negative thoughts and low expectations for the future
• spirals can also be positive, so you have to disrupt the negative downward spiral and facilitate positive triggers

Question 23

cognitive techniques in CBT

Answer 23

• identify automatic thoughts and challenge them
• bring thoughts in line with the event instead of solely negative or reframing them positively
• observe thoughts, feelings & behaviour, consider alternative explanations, solve problems rationally
• orientation toward therapy as an experiment (try something to see if it works)
• match developmental level (insight and abstract thinking)

Question 24

behavioural techniques in CBT

Answer 24

• keep track of mood and activity, develop a list of rewarding activities (that produce pride and pleasure)
• change habits (addressing environmental obstacles and skill deficits)
• monitor how mood is being affected by these changes

Question 25

predictors of positive outcomes for CBT

Answer 25

- combined behavioural activation and thought challenging - involving parents in the intervention - efficacy goes down as severity increases

Question 26

cultural CBT study

Answer 26

- comparing interventions for depression in non-WEIRD samples - CBT, economic, integrated all led to reduced symptoms in low/middle income countries - interpersonal trending toward effectiveness, but not reliable yet

Question 27

antidepressant medications

Answer 27

- much more widely documented in adults, some don't work at all/less in children (brain development/metabolism differences)

Question 28

tricyclics

Answer 28

- prevent reuptake of serotonin and NE or increasing responsiveness of receptors - not effective in youth

Question 29

monamine oxidase inhibitors

Answer 29

- MAO (enzyme) should break down neurotransmitters, so blocking them will increase their levels in the synapse - some mixed evidence of efficacy - potentially fatal side effects (tyramine)

Question 30

selective serotonin reuptake inhibitors

Answer 30

- specifically focused on serotonin - evidence for fluoxetine efficacy in teens - not fatal in overdose - some negative side effects - takes weeks to work

Question 31

serotonin and norepinephrine reuptake inhibitors

Answer 31

- also block NE - still takes weeks to work

Question 32

black-box warning for SSRIs

Answer 32

- suggestion of increased risk of suicide - warns of dangerous side effects - data from all RCTs using antidepressants showed higher levels of suicidality compared to placebo (no deaths from suicide) - other studies show decreased rates of suicidality - more recent studies found no association between use of Prozac and higher suicidal ideation in teens

Question 33

media coverage study of suicide and SSRIs

Answer 33

- investigating whether media coverage and warning labels lead to lower use of SSRIs and increased suicide risk - looking specifically at psychotropic poisoning (underestimate of SAs) - found decreases in prescriptions after the FDA warning - found an increase in psychotropic poisonings after the warning - no change in completed suicide before and after

Question 34

course of action for using SSRIs for youth

Answer 34

- discuss risk and benefit: could increase risk of suicidal ideation (could increase your energy which makes you more likely to proceed with an attempt) - leaving depression untreated can also increase risk of suicide - SSRIs are efficacious all around the world for treating depression

Question 35

treating depression in preschoolers

Answer 35

- diagnosis in preschool is still new, so not much data - limited data on psychiatric drugs - version of parent-management training focusing on helping parents manage their children's moods - helping kids increase positive mood (so there is less room for negative) - therapy is first-line, but if it persists, fluoxetine has the best risk-benefit profile (and continuously monitor)

Question 36

Treatment for Adolescents with Depression (TADS)

Answer 36

- at the time of the study, CBT had some evidence but lots of room to improve the treatment, meds were being increasingly used, combined was being used but no idea if this was actually helpful - sample was 439 youths with moderate-severe MDD - SSRI and combined group did better post-treatment than placebo or CBT alone - CBT was most helpful for suicidality (combined and CBT alone groups vs. SSRIs and placebo)

Question 37

explanations for results in TADS

Answer 37

- CBT didn't outperform a pill placebo - CBT might not work in a more severe sample (it worked better in sub-clinical presentations) - treatment manual was very flexible (clinicians using different CBT methods, so some participants could have received more helpful skills)

Question 38

TADS follow-up

Answer 38

- after 12 weeks, unblinded placebo and SSRI groups (people who were still depressed in the placebo group received treatment) - after 36 weeks from the start (no more control group), all groups were equal - could just be time (MDD episodes are cyclical and we don't have a control group) - could be that CBT takes longer to show positive effects - 1-year post-treatment (returned to treatment as usual), participants were maintaining gains on depression and suicidality