Depression

Question 1

DSM-5 Depressive Disorders

Answer 1

• Disruptive Mood Dysregulation Disorder
• Major Depressive Disorder
• Persistent Depressive Disorder (Dysthymia)
• Premenstrual Dysphoric Disorder

Question 2

DSM-IV Mood Disorders

Answer 2

 DSM-IV Depressive (Unipolar) Disorders

• Major depressive disorder,
• Dysthymic disorder,

 DSM-IV Bipolar Disorders

• Bipolar I disorder,
• Bipolar II disorder,
• Cyclothymic disorder

 Extremes in normal mood

Question 3

DSM-5 Major Depressive Disorder (MDD)

Answer 3

• A single or recurrent depressive episode
• 2 core symptoms:
  
  • Depressed mood most of the day, nearly every day
  • Markedly diminished pleasure/interest in activities

Question 4

Differences between DSM-IV and DSM-5

MDD

Answer 4

Recurrent thoughts of death, suicide, suicide attempts

• 5 or more is needed, (including 1/ or 2/) in a 2-week period
• There has never been a manic episode or a hypomanic episode.
• symptoms not better accounted for by bereavement: persist longer than 2 months (DSM-IV only)

Question 5

DSM-5 Persistent Depressive Disorder

Answer 5

• = DSM-IV Dysthymia
• Depressed mood most of the day, more days than not
• Symptoms are milder, but persist longer than MDD

Question 6

Prevalence of MDD

Answer 6

• Lifetime: 16.4%
• One-year in Australia: 3-5% (male-female)
  
  • Steady increase in prevalence since ’50s
  • Steady decrease in age of onset
    
    • Reasons:
      
      • _{Increased speed of change/stress}
      • _{Decreased social support/family support}
      • _{More acceptable to report symptoms}
      • _{Overdiagnosis}
  • Gender imbalance (2:1)
    
    • Emerge during adolescence, evens out after 65

Question 7

Biological Influences on MDD

Genetic

Answer 7

Genetic:

• Family studies
  
  • High rate in relatives of probands
• Twin studies
  
  • Concordance rates higher in identical twins than in fraternal twins
• Adoption studies
  
  • Data are mixed

Question 8

Biological Influences on MDD

Neurochemistry

Answer 8

• Low levels of
  
  • Noradrenalin, Dopamine, Serotorin
  • BUT no good evidence for mechanism
  • Absolute levels are unlikely to be the cause

Question 9

Biological influences

Brain structures

Answer 9

Amygdala, Hippocampus, Prefrontal Cortex, Anterior Cingulate

>> Differences between people with current or history of depression vs no depression

Question 10

Biological Influences

Neuroendocrine system

Answer 10

• Overactivity in the Hypothalamic-pituitary-adrenocortical axis (HPA Stress Axis)
  
  • Involved in regulating response to stress
  • Excess cortisol (stress hormone)
  • Related to damage to hippocampus?
  • Lower density of serotonin receptors?
• Implicates role of (early) stress in depression
• Interaction between genetic vulnerability and negative life events

Question 11

Main changes introduced in DSM-5

Answer 11

• Changed DSM-IV Mood Disorders to DSM-5 ‘Depressive disorders’ vs ‘Bipolar and Related Disorders’
• Changed DSM-IV Dysthymia to DSM-5 ‘Persistent Depressive Disorder’
• Removed Grief exclusion from diagnosis of Major Depressive Disorder
• Added ‘Disruptive Mood Dysregulation Disorder’ in DSM-5
• Added ‘Premenstrual Dysphoric Disorder’ in DSM-5

Question 12

Specifier: Melancholic features

MDD

Answer 12

• Profound, nearly complete inability to experience pleasure
• Sleep disturbance (e.g. wake up very early in the morning)
• Mood is usually worse in the mornings
• Marked psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive guilt

Question 13

Specifier: Catatonic features

MDD

Answer 13

• movement disturbance symptoms
  
  • immobility at one extreme
  • excessive, purposeless activity at the other extreme

Question 14

Specifier: Peripartum Onset

MDD

Answer 14

• Postnatal depression
• Greater among those women experiencing psychosocial stressors
  
  • perceived lack of support from their partner, family and friends
  • feeding and physical difficulties with the infant
  • stressful life events
  • a previous history of depression
  • complications during pregnancy

Question 15

Specifier: Seasonal pattern

MDD

Answer 15

• Seasonal Affective Disorder
• When there is a regular relationship between the onset of the sufferer’s major depressive episodes and a particular time of the year
• Most often with onset in the autumn or winter months

Question 16

Specifier: Atypical Features

MDD

Answer 16

• Mood reactivity (mood brightens in response to actual or potential positive events)
• Weight gain
• Hypersomnia
• Rejection sensitivity

Question 17

Specifier: Psychotic features

MDD

Answer 17

• Delusions and/or hallucinations are present

Question 18

Specifier: Anxious Distress

MDD

Answer 18

• recognises the strong comorbidity between depression and anxiety
• depression accompanied by significant anxiety
  
  • irrational worry
  • inability to relax
  • a sense of impending threat

Question 19

Learned Helplessness Theory (Seligman, 1975)

Psychological influences

Answer 19

• Lack of control over life events
• Originally an animal model

Question 20

Attribution Theory (Abramson, Seligman , & Teasdale, 1978)

Answer 20

• Internal vs external attributions
• Stable vs unstable attributions
• Global vs specific attributions
  
  • Interaction between cognitive style and life event

(Negative events: internal stable and global >> people with helplessness expectancy >> unable to cope when stressful life events occur >> result in depressive symptoms

Positive events: opposite)

Question 21

Hopelessness Theory (Abramson, Metalsky, & Alloy, 1989)

Answer 21

• helplessness expectancy plus
• negative outcome expectancy

Question 22

Schema Theory (Beck, 1976)

Answer 22

• Pre-existing negative schema
• Developed during childhood (esp if vulnerable)
• Activated by stress
  
  • Results in cognitive biases (memory, attention, interpretation):
    
    • Arbitrary Inference, Overgeneralization, Magnification
  • Depressive Cognitive Triad:
    
    • Negative thoughts about the self, the world, the future become dominant in the consciousness

Question 23

Response Style Theory (Nolen-Hoeksema, 2002)

Answer 23

Rumination

vs.

Distraction, problem-solving, etc.

Question 24

Interpersonal approaches

Psychological Influences

Answer 24

Interpersonal relations are negatively altered as a result of depression

• Depressed people
  
  • have limited social support networks
  • seek excessive reassurance from others
  • have / display limited social skills
  • elicit rejection from others
    
    • >> can maintain or exacerbate depression

Question 25

Interpersonal approaches: **Stress-generation hypothesis** Psychological Influences

Answer 25

* Stress-generation hypothesis (Hammen, 1991; 2006; Liu, 2013) * Depressogenic cognitions and behaviours generate negative life events * Self-generated negative life events may partly explain depression recurrence

Question 26

Biological Treatments: **ECT**

Answer 26

Electroconvulsive Therapy (ECT) * First introduced in 1938 (to treat schizophrenia.) * Only effective treatment for MD prior to 1950s * Applying **brief electrical current to the brain** * Results in temporary seizures * A course of 6 to 10 treatments are administered * **Effective for severe** depression (85%+) * Still used in people **not responsive to other treatment** * **Relapse is common** * Few side effects (short-term memory loss) * Uncertain why /how ECT works

Question 27

**Monoamine Oxidase Inhibitors (MAOIs)** Biological Treatments: Drugs

Answer 27

* Introduced in 1956 first MAOI: iproniazide * **Originally** used to **treat tuberculosis.** * **Slow** to take effect (14-21 days) * MAO breaks down monoamines * Especially serotonin/norepinephrine * MAO inhibitors block Monoamine Oxidase (A and B) * **Serious side effect**: * Can cause ***hypertension*** \>\> ***stroke*** if not on strict diet * Must avoid Tyramine (beer, red wine, cheeses) * Ideally MAOI should inhibit MAO-A only * MAOIs still used: Parnate (tranylcypromine), Nardil (phenelzine)

Question 28

**Tricyclic Medications** Biological Treatments: Drugs

Answer 28

* Introduced early 1960s: Imipramine * **Originally** tried to **treat psychosis**. * Block presynaptic reuptake of Serotonin and Noradrenaline (Norepinephrine) * **Slow** to take effect (14-21 days) * Still widely used (Tofranil, Tryptanol) * **Vegetative symptoms often lift first** * Have more energy, but mood is not elevated * ***Increased suicide risk*** between 10th-14th day * **Negative side effects** are common: * Anti-cholinergic: dry mouth, blurred vision, tremor * Cardiotoxicity

Question 29

**Selective Serotonin Reuptake Inhibitors (SSRIs)** Biological Treatments: Drugs

Answer 29

* Introduced in 1980’s: Fluoxetine (Prozac) * Drugs of choice at present * Seltraline (Zoloft), Paroxetine (Aropax) * Specifically block **reuptake of Serotonin** * Negative side effects are fewer, less serious * Insomnia, agitation, nausea, sexual dysfunction * **Possible risk of suicide,** especially in children/adolescents (Paxil/Aropax) * **‘off label’ use** has been **common** until recently * FDA, TGA now r***ecommends warning labels***

Question 30

**Limitations of using medication** to treat depression

Answer 30

* Drug effects also on non-depressed people * Non-specificity of treatment effects * Timing of action not in sync with effect * Uncertain how/why antidepressants work * Possibly slow changes reversing stress-induced hippocampal damage

Question 31

**Brief Psychodynamic Therapy** Psychological Treatments

Answer 31

* Some evidence for effectiveness * Not a recommended first line of treatment

Question 32

**Cognitive Behavioural Therapy** Psychological Treatments

Answer 32

* **Addresses cognitive errors** in thinking * NOT positive thinking * Schema theory (A.T. Beck , A. Ellis) * Includes behavioural components * Behavioural activation, Behavioural experiments * Outcomes are comparable to drug therapy * **Lower relapse** rates vs drug treatment alone (29% vs 60%)

Question 33

**Interpersonal Psychotherapy (IPT)** Psychological Treatments

Answer 33

* Beginning / exacerbation of depression: * Interpersonal/role disputes * Communication analysis, role expectations * Role transitions * Loss of relationship, marriage, job change, illness * Forming new relationships, expanding old ones * Address **interpersonal deficits** * Limited social support network * Social skills training * Outcomes are comparable to **CBT**

Question 34

**Drugs** vs. **Psychotherapy**

Answer 34

* Recommendations: drugs as first choice * no research-based evidence * Drugs for ‘endogenous/organic/biological’ (melancholic) depression, psychotherapy for ‘reactive’ (non-melancholic) depression * No good evidence * Client characteristics for CBT success: * Introspective, abstract thinker, less rigid, more organised, conscientious * \>\> not suitable for everyone * Medication is recommended for patients with severe depression (Because they wouldn't get up and attend therapy)

Question 35

Developmental Psychopathology **Most common diagnoses**

Answer 35

'Internalising' Disorders * Anxiety Disorders * Mood Disorders 'Externalising' Disorders * Oppositional Defiant Disorder (ODD) * Conduct Disorder (CD) * Attention Deficit Hyperactivity Disorder (ADHD) Developmental Disorders * Autism * Mental retardation * Learning Disorders

Question 36

**Epidemiology** of MDD

Answer 36

* \<1% in preschoolers * 2-3% in school-age children * No significant gender differences * 15-30% in adolescence (14-18 yo) * Risk of depression rises sharply in adolescence * Significant gender differences emerge * Gender ratio 2:1

Question 37

Depression in Adolescence

Answer 37

Cognitive diathesis-stress models * Beck: negative schema * Seligman: helplessness, negative attributions * Cognitive style + Negative events =\> Depression * Predict depression from 12-14 years Mid-adolescence: critical time for MD * Negative cognitive styles consolidated * Increased stress during adolescence

Question 38

What accounts for the **gender differences** in Adolescence Depression?

Answer 38

Possible explanations: * Reporting differences * Self-medication in males (head down the road of substance abuse instead) * Hormonal differences **Higher stress exposure in females** * Sexual victimisation (16-19 peak age for rape) * Body image concerns (80% girls) * Interpersonal negative events * ‘Vicarious stress’ in social network **Higher negative cognitive style in females** * Different coping responses to stress * Rumination (females) vs distraction/problem-solving (males, e.g. with drugs)

Question 39

**Causes** of depression in **preadolescents**

Answer 39

* Do children possess negative cognitive styles? * cognitive diathesis-stress model explains depression from age 12-14 * Negative events =\> cognitive style =\> depression * Role of **depressed parent(s)** * genetic vulnerability * less responsive to children, less contingent to respond, more negative/critical of children * observational learning (poor coping style, more negative emotion and facial expression, depressogenic thinking etc.) * Emotional abuse, neglect (more than sexual or physical abuse) * Secure attachment (protective factor against depression)