Depression Summary Cards (Diagnosis, Epidemiology, Aetiology and Treatments)

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Depression Description/Diagnosis.

Major Depressive Disorder (MDD)

  • Symptoms for most of day & almost every day.
  • Symptoms for at least 2 weeks.
  • Sad mood / loss of pleasure / sleep disturbance / low appetite and weight loss. 
  • Feelings of death & suicide / worthlessness. 
  • Episodic - symptoms present for short while then pass. 

Dysthemia

  • Depressed mood more than half the time for 2 years. 
  • Other symptoms similar to MDD but not as extreme. 
  • Chronic condition - symptoms present for longer periods of time without passing. 

Bipolar Disorders

  • Manic Symptoms are defining feature--> mania = state of intense elation / irritability. 
  • Depressive episodes still occur, highly changeable mood. 

Cyclothemia

  • Chronic form of bipolar --> symptoms milder but ups and downs still noticeable. 
  • Symptoms for at least 2 years. 
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Depression Epidemiology (Prevalence)

MDD

  • One of most common disorders. 
  • Approx 16.2% meet criteria at some point in their lives (Kessler et al, 2005). 
  • Approx 2x more common in women. 
  • High variability accross cultures. 

Dysthemia

  • Much rarer than MDD
  • Approx 2.5 meet criteria at some point (Kessler et al, 2005). 

Bipolar Disorders

  • Bipolar I very rare = approx 1% meet criteria (Weissman et al, 1996). 
  • Bipolar II = approx 2% meet criteria (Merikangas et al, 2007). 
  • Average onset = early 20s. 
  • Women have more depressive episodes. 
  • Cyclothemia = approx 4% meet criteria --> more common than full bipolar disorder. 
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Medical Aetiology of Mood Disorders (Causes)

Medical View

  • 1) Genetics - average 37% heritability in MZ twins, higher than DZ (Sullivan et al, 2000). 

      - chromosome 3 possibly implicated
      - BUT! --> families/twins also share environment as well as genes. 

  • 2) Neurochemicals - Noradrenaline (NA) - Lower levels  = depression. 

    - Serotonin - Lower levels =depression. 
    - Dopamine- Lower levels = depression. 
    - Cortisol - high levels = depression & lower levels of serotonin. 

  • 3) Brain functioning  - Neurogenesis --> reduced neurogenesis linked to depression. Anti-  depressants led to development of new neurons in mice. 

      - Stress can suppress neurogenesis & cause depression. 
      - Neurogenesis slows down as we age but all elderly not depressed.
      - Amygdala - emotional thermostat - elevated activity in MDD (Sheline et al, 2001). 
      - Dorsolateral PFC - underactive/diminished volume in MDD (Davidson et al, 2002)

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Social Aetiology

  • Stressful life events may trigger episodes of depression (Kessler et al, 1999)
  • Loss and humiliation likely triggers (Kessler et al, 2003)
  • But not everyone becomes depressed after these social experiences
  • Some people must be more vulnerable
  • Genetics / neurochemicals as predisposing factors?
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Psychodynamic Aetiology

  • Freud - "Mourning and Melancholia" - 1917. 
  • Depression from fixation at oral psychosexual stage
  • Causes person to become dependent on others to maintain self-esteem.
  • Depression can be caused by loss of a loved one. 
  • Person tries to identify with lost one but feels resentment and anger for desertion. 
  • Anger is not expressed --> turned inward causing self hatred. 
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Cognitive Aetiology

  • Negative thinking is what causes depression.
  • Beck (1967) 
    • Negative triad (negative views of self, world and future)
    • Negative schemata (acquired in childhood due to negative events)
    • Cognitive biases (tendency to process info in negative ways / ignore positive info)
  • But cause and effect is a major issue:
    • Negative Thinking <======?=====> Depression

Examples of Cognitive Biases:

  • Arbitrary Influence = friend didn't answer phone, must be avoiding me.
  • Overgeneralisation = argument with friend, everyone hates me.
  • Magnification= overplay -ve events/ underplay +ve events.
  • Excessive Responsibility - if goes wrong it is my fault. 
  • Self - reference = my failures must be uppermost in other people's thoughts.
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Behavioural Aetiology

  • Skinner (1953) - lack of positive reinforcement = loss of positive behaviours. 
  • Lewinsohn et al (1990) - fewer rewards for positive behaviour = fewer behaviours. 
  • Depression is often maintained by bringing attention and sympathy. 
  • The depressive mood is reinforced and is maintained in this way. 
  • Depression similar to learned helplessness--> Aspects of life uncontrollable = give up (Seligman, 1974). 

INTEGRATION OF AETIOLOGY BECOMING MORE WIDELY ACCEPTED!

  • E.g. predisposed with genes/faulty neurotransmitters but may be triggered / maintained by social factors, cognitive factors etc. 
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Biomedical Treatments of Depression

1) Anti-depressant drugs

  • Monoamine Oxidase Inhibitors (MAOI) 
    • stops action of an enzyme which causes breakdown of neuron activity. 
    • Raises levels of NA and Serotonin  raised activity. 
    • BUT! can cause stroke, hypertension, toxicity, death. 
  • Tricyclics (TCAs)
    • prevent reuptake of NA = increased levels and may also increase serotonin levels. 
    • Better than MAOI (Stern et al, 1980) but not all respond. 
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
    • Inhibit reuptake and reabsorption of serotonin = serotonin in synapses longer = increased chance of binding to receptors. 
  • Noradrenaline Reuptake Inhibitors (NRIs)
    • selectively block reuptake of NA = more NA  improved mood. 
    • Seperate SSRI and NRI useful for distinction between serotonin and NA deficiency. 
  • Serotonin and Noradrenergic Reuptake Inhibitors (SNRIs)
  • More effective than SSRI (Willard et al, 2002)
  • Aim to balance NA and Serotonin
  • Side effects = cardiovascular disease ---> hypertension. 
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Efficacy of Drug Treatments

  • Effective in around 2/3 patients (Fawcett & Barkin, 1997)
  • Data only provided for those who remain in the studies (Bollini et al, 1999). 
  • Bollini et al (1997) meta analysis --> best improvement on medium dose, 53% improved. 
  • Moncrieff (2007) - drugs don't relieve symptoms, just sedatives, don't improve prognosis. 
  • Kirsch et al (2008) - for most patients anti-deps no more effective than placebo. 
  • Fournier (2010) - anti-deps work better for more severely depressed. 
  • If drugs so effective why still so many sufferers?
  • Seem to reduce symptoms but do they cure?
  • Over-prescribed? --> may be seen as the easy option to treat depression. 
  • If they are just sedatives but are beneficial then does this matter?


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Medical Treatments Continued

Electro Convulsive Therapy (ECT)

  • Cerletti (1938) - electric current to skull = cortical seizure and convulsions.
  • For MDD if no response to drugs. 
  • 6-10 treatments over 3-4 weeks. 
  • Rey & Walter (1997) - 60% show improvement. 
  • BUT!! - memory loss, painful and often terrifying. 

Transcranial Magnetic Stimulation (TMS)

  • Gentle ECT? --> brain stimulated without seizure. 
  • Lyons & McLoughlin (2001) --> may be more popular and effective than ECT.
  • Mark et al (2010) - 15% showed improvement. 

Psychosurgery (Lobotomy)

  • Moniz (1930s) - frontal lobotomy --> controls thoughts and emotions. 
  • Cut pathways = fewer emotional thoughts & behaviours. 
  • High success rates - 50% improvement. 
  • BUT! - memory problems, withdrawal, seizures. 
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Behavioural Treatments

Behavioural Activation Therapy

  • Aims to use principles of learning to change maladaptove behaviours (Weitan, 1998). 
  • Behaviour has been learnt so can be unlearned in the same way. 
  •  
    • 1) pleasant events schedule --> reintroduce pleasurable activities. 
    • 2) rewarded for non-depressive behaviours. 
    • 3) trained in effective social skills. 
  • All steps must be done for improvement. 
  • Works best with mild depression (Jacobson et al, 1996). 
  • Based on Behavioural Activation component of Beck's therapy. 
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Psychoanalytic Therapy

  • Problems caused by inconscious childhood conflicts and loss. 
  • Defence mechanisms employed but anxiety and guilt may still surface. 
  • Must bring unconscious conflicts to surface so can be dealt with --> remove repression. 

1) Free Association

  •  
    • client free to talk about whatever comes to mind. 
    • relaxation leads to free flow of ideas
    • gradually will uncover unconscious material. 

2) Dream Analysis 

  • Ego defences lowered during sleep --> unconscious material comes forward. 
  • Often disguised in symbolic form --> analyst must interpret symbols. 
  • Transference - client transfers emotions to therapist --> therapist interprets. 
  • Resistance - painful memories may be blocked --> stop talking / change topic --> therapist must interpret these blocks. 
  • Shedler (2010) - very effective (0.97 and 1.51 effect sizes) but very lengthy process. 
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Humanistic Therapies

  • All seek to be self-actualised - if prevented from doing so can cause anxiety. 
  • Clients assisted to find own course of action (not very directive)

1) Client-Centred Therapy (CCT) (Rogers, 1951)

  • Provides supportive emotional climate, client dictates pace and direction of therapy. 
  • Focus on present and conscious material. 
  • Distress due to incongruence between actual self and ideal self. 
  • Aim to help foster self-acceptance and restore congruence. 
  • 40% recovered (Pearce & Goss, 2011). 

2) Encounter Groups - Talk in groups through structured activities - climate of trust helps to accept self. 

3) Gestalt Therapy

  • Help client become whole by acknowledging all aspects of them (Rathus, 1994)
  • Talk about conflicting aspects of personality. 
  • Smith, Glass & Miller (1980) - 474 studies - improvement seen than 75-80% untreated.
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Cognitive Therapies

1) Rational-Emotive Therapy (Ellis, 1977)

  • irrational thoughts and expectancies cause distress. 
  • encourage clients to challenge and correct expectations. 
  • replace with more rational / realistic ones. 

2) Cognitive-Behaviour Therapy (Beck, 1976)

  • Negative schemata = negative thoughts --> from early negative events. 
  • Focus on negative events and ignore positive --> draw negative conclusions. 
  • Must make client aware of errors and change thinking --> show how irrational. 
  • Effect size of 0.83 --> Thase et al (2000) - effective in 77% at 16 weeks. 
  • Now computerised CBT. 

3) Mindfulness Based Therapy

  • Aim to reduce relapse in those who have had multiple episodes. 
  • Help to show link between negative thinking and negative mood. 
  • 8 week therapy - Breathing, Meditation and Yoga.

Teasdale (2000) relapse reduced from 66% to 37%

Kuyken (2008) 60% relapse for drugs only, 47% in joint group. 

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Overall Evaluation of Therapies.

  • Eysenck (1952) - 2/3 recovered with treatment but 2/3 without treatment also recovered. 
  • Bergin (1995) - 83% improved - psychoanalysis showed best improvement 
  • Seligman (1995) - 54% treated said "made things better"
  • Stiles et al (2008) - CBT, Psychoanalytic and Person-Centred equally effective. 
  • Cuijpers et al (2008) no major diffs between therapies, all effective. 
  • Gloaguen (1998) - CBT = more relapse prevention than drugs. 
  • Other therapies effective without side effects of drugs. 

BUT!!

  • Mulhauser et al (2010) - therapies effective but pinning down reason for effectiveness is tricky. 
  • Not all therapies work for everyone - usually a case of long trial and error to find correct treatment.
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