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Four Components of Major Depressive Disorder
- 1.Cognitive: Ruminating thoughts of
- 2. Behaviour: Psycho-motor agitation/retardation/ eating
- fluctuations/sleep disturbance/ suicidal gestures
- 3. Physiology/sensations: sad expression/
- irritability/somatic complaints
- 4. Affect: feeling sad/lack of pleasure distinctively
- different than pre depression
Subtypes of Depression
1. Major Depressive Disorder (MDD)
2. Dysthymia (DD)
3. Episodic vs. Chronic Specifiers
Aetiology MDD: Diathesis Stress Model Perspective
- 1. Interaction of stressful life events & predisposition
- (stressful event may be positive)
2. Interpersonal loss/feelings of humiliation & defeat
3. Women's response style = ruminations vs distraction (more male)
Aetiology MDD: Reinforcement Perspective (Lewinsohn)
1. Less contingent reinforcement - Leads to -Less activity
(low rate of bhv causes all other symptoms of dep)
2. Depressed behaviour can be reinforced
Aetiology MDD: Biological Perspective
1. Genetic contribution:
MDD=50%/ DD= 10%.
- 2. Short Allele of 5HTT: (serotonin) + stress above
- individual threshold triggers gene.
stress response system dysfunction +hormone change
- 4. Neurological: structural/circuitry
- dysfunction/ neurotransmitter deregulation in
Aetiology MDD: Cognitive Perspective
(Becks ABC model)
- -Cognitive Biases, distortions & errors: (ie filtering/ overgeneralising/ perceived failure etc)
Process information and form view based on prior experiences/schema is re-activated by similar experiences
-Schemas determine how they will cope with future problems
Aetiology MDD: Learned Helplessness Perspective (Seligman)
- - (Pervasive) Hopelessness; negative expectations of future
- events & belief of no control over negative events.
- explain neg events as internal, stable & global (depressogenic attributional style
) often results in perceived failure.
- only remember bad events/catastrophizing
Aetiology MDD: Interpersonal Perspective (Weissmand & Makowitz 1994)
1. Disturbance in formation/maintenance/ or renewal of bonds historically & currently
2. Loss of relationship in preceding 6 mths
3. Association with global deficits in social functioning
Aetiology MDD: Integrative systems (barlow & Durand 2002)
1.Bio vulnerability/ Psych vulnerability/ Stressful life events
2. Maintenance of depression via
(a) Activation of stress hormones/change in neurotransmitters
(b) Activation of neg attributions
- (c)leads to problems in interpersonal relationships and lack
- of social support.
Prevalence of MDD
MDD- Lifetime Prevalence =16%/
Dysthymia - Lifetime Prevalence = 3%
- -Leading cause of diability worldwide (10% of all
Onset of MDD
- 1. Early 30's
- 2. 5% increase in younger ages 18-29yrs
Course/ Duration of MDD
- -Most have at least 2 episodes (Mean 5-6 episodes in
-Most recover from episode <6 months
*Dysthymia at least 2 years.
Gender Difference in MDD
More women than men across cultures
- *Women's response style: more ruminations compared to men who use distraction methods more.
- *Gender roles: women learned helplessness/victim
DSM Diagnosis/ Criteria for MDD
Depressed mood and/or loss of pleasure (anhedonia) in all/most activities for at least 2 weeks + 4 symptoms (below)
2.Appetite disturbance (5% change in weight in 1mth)
4.Impaired thinking/difficulty concentrating
5.Feelings of worthlessness
DSM Diagnosis/ Criteria for Dysthymia
1.Depressed mood for most of the day, more days than not, for 2 years + 4 symptoms for MDD.
2.No break in depressed mood of more than 2 months.
3.Less severe but more chronic symptoms of MDD.
Severe form of MDD
Requires biological treatment (Med+ECT)
- Psychotic features/ Postpartum onset
- (within 4 wks. of birth).
Vulnerability Factors for Depression
1.Previous history of depression
2.Sensitivity to adverse events
6.Low coping skills
8.Low threshold of evocation of self-schemata
9.Children under 7yrs
Protective Factors in Depression
2.High frequency of pleasant events
3.Self-perceived social competence
- 4.High level of social support ( *clinical sig. to relapse
Suicidal ideation & NSSI
-Symptoms of dep usually present
-10:1 ratio for attempts to completion rates
(F=15-19yrs more attempts/ males higher completion rates with age)
-NSSI: Common to Borderline/Substance abuse/ ED/ MDD/DD
- *Biggest predictor of Completed suicide*
- Desire to end one's life combined with ability to enact lethal self-injury.
Prevalence of Suicide
3rd Leading Cause of death in 15-24yr olds
15-19yrs -19% males/15.9% females
20-24 yrs -24.2% males/17.2% females.
Biological Treatment for MDD & DD
- Medication:Target levels of neurotransmitters (serotonin & norepinephrine)
- SSRI's /NSRI's/Tricyclics/MAOI's/St John's Wart
- -2-4wks min before improvement/1-2 mths to reach optimal dose/ if dep resistant at optimal dose or melancholic episode may need ECT.
- -Course= 3 per week for 2-7 weeks
- -Side effects severe but transient (memory loss)
Psychotherapy Treatment of MDD & DD
3.Psychodynamic (not evidence based)
4.Behavioural Activation & Exercise
5.Light Therapy (for Seasonal Affective Disorder)
- 6.Interpersonal & Social Rhythm Therapy (Focus on
- interactions b/w symptoms & social interactions)
CBT: Treatment of MDD & DD
- Psycho-education - explain role of dep, symptoms &
- responses/ ABC model- role of belief systems & schemas/ Homework & compliance.
- -Cognitions -identitfy helpful vs unhelpful cogs
- -Antecedence,belief's & consequences-Challenge unhelpful /underlying thoughts/ acceptance /alternative thoughts & responses.
- Tolerance/acceptance of unpleasant emotions
- -Behaviours -Increase activity/schedule pleasant
- events/ self-reinforcement
Interpersonal Therapy:Treatment of MDD & DD
- -Focus on identification & amelioration of patient's
- interpersonal difficulties contributing to current depression.
- -Typical problem areas; unresolved grief, interpersonal
- disputes, role of transitions, interpersonal deficits.
- -Importance for relapse prevention/ good evidence for
Behavioural Activation & Exercise (Lewinsohn): Treatment of MDD & DD
-Encouraging patient to perform behaviors that will improve the patient’s mood and achieve the patient’s goals/ discourage behaviour that interferes with achieving goals.
-Focuses on the consequences of behavior:
Evidence based efficacy = to CBT & meds
Treatment Comparisons in MDD & Dysthymia
- CBT, IPT and Tricyclic meds equally effective in approx 50-70% of cases.
- (more than placebo or brief Psychodynamic)
- -Long term efficacy better for CBT
- *30% well for CBT
- *26% well for IPT
- *19% well for Tricyclics
- *20% well in placebo
Relapse predictors for MDD and Dysthymia
-Chronicity or no. of episodes
-High levels of emotional expressiveness
-Post-treatment severity & Cognitive style
-Dissatisfaction with major life areas
-Coexisting medical Problem *significantly higher risk
Relapse Prevention for MDD and Dysthymia
-50% relapse rate if cease medication (Stay on meds to 6-12mths once better).
- -CBT has 20% lower relapse rate after 12 wks
-Adaptive coping strategies & plan in place
-Pleasant activity schedule