depression

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clinical characteristics A01 (unlikely to come up)

5 of: depressed mood,Psychomotor agitation, feelings of worthlesness, significant weight loss/gain, diminished sense of pleasure, insomnia, fatigue, inability to concentrate, thoughts of death/suicide

must not be attributable to bereavement

categories reactive/ endegonous

the "common cold" of psychological problems (seligman)

10%of men and 20% of women have one ep. in lifetime

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clinical characteristics A02 (unlikely to come up)

poss. gender bias in statistics, as twice as many women get depression than men. Why

  • women suffer from types of depression not applicable to men e.g. post partum, menopausal
  • women are more likely to get help for depression, so men are more likely to go undiagnosed and not show up on official figures despite similar incidence of depression to women

unlikely to come up as an A02 subject, mainly because of overlap with issues with diagnosis and classification 24 marker. if it does, use points regarding depression as an umbrella term with many types e.g unipolar (90%) and bipolar (10%).

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issues with classification and diagnosis-culture

mix of A01 and A02- too difficult to seperate in this topic, so make the point and move on differing conceptualisations of health- classifications developed with reference to western world only, western theorists may not take into account the varying ideas about health and illness, which may mean that psychological disorders like depression present themselves in different ways outside of the influence of western culture.                                                                                                    For example, China's historical conceptualisation of helath empahasises a strong link between body and mind- therefore, the divide between physical and psychological disorders in the west may not be present.

chinese DSM equivalent contains classification for neurasthesia including tiredness and other physical symptoms

Kua e.a Chinese participants later diagnosed with depression first complained of head and chest pain

incidence rates may also be culturally biased due to diff. levels of stigma attached to depression

Vega e.a Puerto Rico family shame

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issues with classification and diagnosis- validity

internal validity- umberellla term, e.g. umipolar and biplar. does not account for severity of symptoms, so 5 mild classified as depression whilst 3 severe not. Also, such a wide range of symptoms that one depressive may have completley different set of symptoms than another. different causes and different intervention required. DSM not true description of depression. 

Comorbidity overlap symptoms, difficlulty seperating disorders e.g agoraphobia and depression. serious consequences of comorbitiy- symptoms may be wrongly attributed to diff. disorder, other one remains undiagnosed and untreated.

Kessler- comorbitity anxiety disorder and MDD 57% comorbidity with other 74%

Beck- high concurrent validity between measures

Andrews-differnet in classification systems does not produce a high no of discrepant diagnoses

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issues with classification- reliability

  • consistent measurement of symptoms Kramer- research into diagnosis criteria pays little attention to evaluation of efficacy
  • the presentation of symptoms alone doesn't neccesarly lead ot an accurate diagnosis
  • reliability of criteria. multiple diagnosis classification system, diverse range of symptoms included
    • doesn't comment on severity of symptoms experienced- does not distinguish between mild and severe depression in this way, only by number of symptoms experienced.may lead to a depressed person not being diagnosed due to a small number of symptoms
    • HOWEVER, Andrews- difference in classification systems does not produce a high number of discrepant diagnoses. Beck- high concurrent validity between measures
  • Miller and Goldberg- GPs more skilled able to get clues from distressed patients
  • Van Baumgarten- GP diagnosis depends largely on family history
  • Dickman e.a- diagnosis of a ficitional patient by 820 volunteer GPs had a 24% accuracy rate
  • more skill= better diagnosis- as diagnosers have varying levels of expertise, not reliable
  • Keller- inter-rater reliability for 154 p 54% for 2 psychiatrists
  • Stirling- average consulting time for GPs 8 mins, for psychiatrists 1hr. A increase of 50% of GPs time led to a 32% increase in accuracy of diagnosis. practical applications. Application not universal- criteria not relaible
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biological explanations-genetics/ n-n

  • twin studies- any difference attributable to genetics- shared enviroment for twins minimises influence of nurture as a factor differentiating between MZ and DZ concordance rates
    • Allen e.a- MZ= 40% DZ= 11%
    • McGuffin-MZ= 40% DZ= 20%
  • self-fufilling prophecy, MZ twins look identical, so may be treated more similarly. Therefore, increased concordance rates may be due to nurture. Also, MZ twins were not 100%
  • family history-futher supports role of genetics without methodological probs as twin studies
    • Gershon- meta-analysis found that relatives of depressives were 2-3x more likely to develop depression than the general population
    • Silberg e.a- Virginia study found a heritability factor of 28% for depression with 72% nurture
    • Wender- adopted children of bio parents with depression 8x more likely to develop depression than their adoptive relatives
  • However, other studies have implicated the role of nurture in depression. Brown and Harris- 404 working class mothers in longitudinal study. Childhood trauma significant predictor of depression. Better to adopt a diathesis stress model- because concordance rates not 100%,.
  • Keller 85% recovery with CBT and drugs 55% when either used in isolation. DSM reccomends use of both
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biological explanations- biochemistry

  • neuroanatomy
    • damage to frontal lobe, implicated in planning, judgement emotion regulation e.g.post-stroke depression. Limbic system damage
  • amines
    • noradrenaline, dopamine, serotonin are neurotransmitters which are lower in depressives.  
    • Teutine found low serotonin in depressives urine.
    • Treatments for depression often increase levels of available serotonin, either by stimulating its production or preventing its breakdown/reabsorption, e.g. tricyclics.
    • Delgado- tryptophan negative diet led to depression- essential for creating amines
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biological explanations- psych as a sci

  • uses physiological measures- gene mapping, objective and not affected by any existing bias of researchers.
  • only links, not cause and effect.
  • many studies regarding neuranatomy are only case studies- not scientific as sample is too small and not representative of wider population. constrained by ethics, as it would be unethical to replicate an injury in a person e.g  with brain damage caused by stroke, causing considerable irreversible damage for research means is unjustifiable. therefore constricted.
  • Furthermore, cannot establish causal relationship, although delgado have managed to suggest one.
  • ethics impose considerable restrictions on research in this area
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biological explanations-prac. app

  • Prac. app.
  • Thase and Kupfer- using medication better than taking placebos
  • Prien- 75% of cases had a reduction in symptoms when taking drugs compared with 33% placebos
  • bio explanations have made  a major contribution to the understanding of ther disorder
  • however, contrast with CBT, a psychological treatment which aims to replace maladaptive thought processes with adaptive ones. focuses on changing thoughts in Beck's cognitive triad- negative thoughts about self, the future and others. Adresses negative schema acquired in childhood. Keller 55% recovery rate when CBT used.
  • neither one nor the other, combined apporoach better, as reccomended by DSM IV, and by Keller (see earlier card)
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psychological explanations- socio-cultural

  • socio-cultural explanations-
    • Brown and Harris-404 working class mothers in longitudinal study. Childhood trauma significant predictor of depression.
    • Brown and Harris- two types of factors precipitating depression- severe short term and milder long term difficulties accompanying a vulnerability
  • psychodynamic explanations-
    • negative feelings towards parents is redirected towards the self
    • fixation at oral stage becomes too dependent on others
    • a seemingly minor loss is reacted against in a disproportionate manner. Actual v. symbolic loss. brings up unresolved issues.
    • Bowlby argues childhood seperation leades to a badly formed IWM demonstrated in rhesus monkeys
  • cognitive explanations-
    • Gotlib and McLeod- caused my negative schemas acquired in childhood. is compatible with other explanations which focus on childhood
    • Beck- catastrophising, cognitive triad. interferes with congitive processing, impairing perception, problem solving and memory.
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psychological explanations-behavioural

                                                        Behavioural theories

  •  
    • Ferster-a reduction in positive reinforcement leads to depression. expanded upon by Lewinsohn who argued that depressive behaviour is reinforced by the sympathy obtained from the person's friends and relatives. many ethical issues regarding placing stigma on the depressed person arise from this explanation. contrast with seligman
  •  
    • In contrast, Seligman proposes that depression is caused by the occurence of events that the induvidual cannot control, either positive or negative. Such theories are supported by his 1974 research which used dogs to test the hypothesis regarding uncontrollable events leading to depression. 63% of the dogs placed in an unavoidable shock condition did not leave when it was made possible to escape being shocked in 9/10 trials. This confirms the theory of Learned Helplesseness. If depression can be learned, it means it can be unlearned as well
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psychological explanations- IDA

  • Nature versus nurture
    • may be rooted in inheritable factors McGuffin MZ 46% DZ 20%. Must be at least partially inherited e.g. Wender (relatives 8x more liekyl to develop depression than general population).
    • NOT 100% concordance rate Silberg e.a (virginia study 28% genes 72% enviroment)
    • Need to use diathesis stress model in order to understand depression fully. Gene-enviroment interactions exemplify this form of apprach, as it is hypthesised that enviromental factors such as diet, lifestyle factors etc. may cause the activation or suppression of genes coding for behaviours or processes. not mutually exclusive and may interact with each other
  • practical applications
    • CBT, cognitive triad, Beck
    • DeReubis-8 weeks 43% CBT 25% placebo
    • Major contributor to understanding of disorder and how to treat it.
    • alternativley, Paychodynamic methods and treatments have been used in therapy to try and identify causes of depression for induvidual. Mufson et al 75% recovery PD, 46% control. can also be useful
    • BUT, not the whole picture. BY highlighting only psychological causes, expl. and  treatments ignore contribution of bio factors. Combined approach shown to be more
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psychological explanations- IDA

  •  
    • effective than using psych or bio on its own. Keller et al 85% CBT and drugs, 55% of either treatment in isolation. DSM IV reccomneds combines approach for trating non-psychotic MDD. Although useful practical applications, limited in usefulnees when used in isolation- its narrow focus limits it usefulness in application
  • psch as a sci
    • variable in its adherence to Popperian standards of scientific process, poss. due to the fact that many psych explanations are based on interal unobservable cognitions and processes. Cannot be falsified, as it is near impossible to measure and test them. For example, cognitive approach argues that depression is caused by catastrophising and faults in cognitive processes. such faults cannot be easily tested, meaning the stage of testing during hypothesis formulation cannot be satisfied and as such may not be regarded as scientific.
    • however, there is some expreimental evidence for the validity of psychological theories originating from rates of recovery following treatments adapted from these theories. Mufson  75% PD 46% control,  Dereubis 43% CBT 25% placebos. does have some experimental evidence in favour of it, may be more scientific than at first glance.
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psychological explanations IDA

  •  
    • however, evidence in favour of effectiveness of treatments is different than that confirming mechanisms, poss. low internal validity, as although treatments may work, it is uncertain if they work due to their addressing of e.g. cognitive faults or other factors. therefore, cannot be truly falsified using this method and as a result are unscientific. Even psych explanations which focuson outward, measurable behavioural factors have little evidence supporting them.

 

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biological therapies- A01

  • Drugs A01
    • SSRIs
      • blocks amine reabsorbtion in synapses
      • accumulation of seorotonin
    • Tricyclics
      • stimuate amine production
    • MAOIs
      • inhibits Monoamine Oxidase,which normally breaks down monoamines e.g. serotonin
  • ECT A01
    • 70-130 volts
    • 0.5-5 volts
    • unilateral/ bilateral
      • stimulates either one or two sides of brain
      • unilateral thought to be safer, less memory loss and other side effects
    • mechanisms
      • unsure of exact workings
      • thought to stimulate amine production, decrease blood flow to frontal temporal lobes
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biological therapies- appropriatness

  • cost-benifit analysis-if only effective for a limited amount of time, may not be justifiable if it has any considerable cost to patient taking it
  • risk of suicide- NICE 2009 report 50% increased risk of suicide when taking SSRIs. with such risks, any possible benifits, which already seem diminished when considering it only works for a limited amount of time, seem to small to justify the use of any SSRIs. threat to life makes any use unjustifiable. Ferguson meta-analysis 85,000 patients taking SSRIs twice as likely to attempt suicide
  • ECT and negative associations- many patients may have negative associations with ECT, which has been portrayed negativley in the media. having ECT may be a frightening or unnerving experience.
  •  Unjustifiable for everyone?- Barbui et al found risk of suicide deacreased with age, and that taking SSRIs for over 50s actually had a preventative effect. risks not the same for everyone. Furthermore, for patients with serious depression or psychotic symptoms who are currently a suicide risk, any improvement however temproary may be justifiable.
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biological therapies- effectiveness

  • how is effectiveness operationalised?
    • improvement- Dereubis 43% CBT, 23% placebos, Prien 75% of cases showed a reduction in symptoms compared to 33% placebos. hard to judge through numbers alone, as they operationalise effectiveness differentely. Some
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psychological therapies-cognitive

  • cognitive A01
    • replaces maladaptive with adaptive thought processes
    • ABC model (Ellis)
      • information obbtained by therapist about
        • activating event
        • beliefs
        • consequences
      • and challenges by these by proposing alternative explanations for events. in doing so, the therapist aims to expose core beliefs leading to depressive behaviour
  • cognitive A02
    • ethics- therapy is challenging  and may be extremely stressful for some patients, as in exposing core beliefs therapists may have to touch on some disturbing or intensely personal information. therefore, it is very important that the therapist carrying out the CBT is highly trained in order to control any possible costs of getting the therapy. Research has shown that recovery rates are highly variable depending on the expertise of the person carrying out the therapy. this means that in order to be justifiable and ethical, therapy must be carried out by a highly qualified induvidual capable of making the therapy effective and reducing costs. However, very nature of therapy seems to cause harm to patients- implies
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psychological therapies- cognitive

  • the fault lies in patient for their depression- by making a cognitive error, any negative event that happens in the depresive's life cannot be to blame for their depression. In this definition, reactive depression is just another form of endegenous depression as it originates ultimately from the self. BUT no side effects.
  • studies
    • dereubis 25% placebos, 43% CBT, 50% drugs. maintained over 16 weeks.
    • Kuyken 62 participants over 15 months. 47% relapse CB, 60% relapse with drugs
    • Bryant client's participation with h/w determined success of treatment
    • Blackburn and Moorhead  CBT more effective over periods of 1 yr +
    • Keller- 55% in isolation, 85% combined
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psychological explanations-psychodynamic

  • dream analysis, free association, productive talking therapy, tranference (unaaceptable feelings are projected onto therapist acceptable). In order to acheive catharsis.
    • Holmes-P.D effective for some induviduals
    • Eynsenck- -P.D worse than nothing 66% of control group recovered spontaneously, whilst 44% of P.D recovered. Leads to overdependence on ineffective methods
    • Mufson
    • Leichsenring- meta-analysis CBT v. PD- no difference between treatments
    • Thase- 43% combined P.D- rates not directly comparable
    • Horowitz- gains from PD not maintained over time
    • quality of treatment= quality of therapist
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