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What causes depression?
Most likely an interplay of factors.
- ~ Relatives of patients with mood disorders have 1.5-3x greater risk of a mood disorder.
- ~ Most frequent mood disorder in relatives of those with BPD is MDD.
- ~ Severity, recurrence and age of onset affects rates in relatives.
- Genetic contribution:
- ~ Severe mood disorders = stronger genetic contribution.
- ~ Genetic contribution to depression estimated at 40%. Environment plays a large role - it is the unique, non-shared experiences that interact with a biological vulnerability to cause depression.
- ~ Serotonin is an important gene. Short version = more severe symptoms.
- Neurotransmitter systems:
- ~ Low levels of serotonin implicated in etiology of mood disorders, but only in relation to other neurotransmitters.
- ~ Primary function of serotonin is to regulate emotions.
- ~ Currently think it is a balance of various neurotransmitters
- ~ People with diseases affecting the HPA axis often become depressed. There is increased cortisol levels in depression.
- Psychological factors:
- ~ Learned helplessness: become depressed when make the attribution their actions cannot control their circumstances. Unhelpful attributions: internal, stable, global.
- ~ Negative cognitive styles are a risk factor for depression.
- ~ Beck's cognitive model: depression is from a tendency towards automatic negative interpretation of events. Cognitive errors include overgeneralisation, black or white thinking, filtering, personalisation. These errors are about the self, the world and the future (depressive cognitive triad).
- ~ Response style theory: duration, severity and course are consequences of the way the individual focuses on and appraises their depressive symptoms. Rumination predicts depression onset and duration.
- Temple-Wisconsin study:
- ~ Looking at cognitive vulnerability to depression.
- ~ Classified as high or low risk and followed prospectively for 5 years.
- ~ High risk participants were more likely to experience MDE.
What is a major depressive episode?
- DSM criteria:
- 5 or more symptoms present during the same 2 week period:
- ~ At least one symptom is depressed mood most of the day nearly every day OR anhedonia.
- ~ Significant weight change or change in appetite.
- ~ Insomnia or hypersomnia
- ~ Psychomotor retardation or agitation
- ~ Loss of energy
- ~ Worthlessness/guilt
- ~ Poor concentration, indecisiveness
- ~ Thoughts of death, suicidal thoughts/plans.
Symptoms represent a change in previous functioning and are persistent (occur for most of the day nearly every day during the same 2 week period).
Specificy: psychotic features, chronic, catatonic, melancholy, atypical features, post-partum, longitudinal course, seasonal pattern.
What is major depressive disorder?
MDD is characterised by one or more MDE. Either MDD single episode or MDD recurrent.
What is the course of MDE?
- Duration of MDE is variable. 6-9 months if untreated.
- Majority of cases have complete remission.
- Most will have a second episode. The chance of another episode increases with each subsequent episode.
- Psychosocial stressors precipitate early episodes.
Treatments for depression?
Typically advocate combined treatments. e.g. drugs (for short term effect) and CBT/IPT (for long term benefit and maintenance).
- Antidepressant medication:
- ~ Effective in MDD and dysthymia, but 40-50% don't respond.
- ~ Need to help people to maintain their medication.
- ~ Need to closely monitor to make sure medication levels are appropriate.
- Cognitive therapy:
- ~ Examine and modify the faulty negative appraisals.
- ~ Client is taught to recognise their cognitive distortions and substitute more realistic interpretations.
- ~ A combination of behavioural and cognitive techniques.
- ~ Behavioural treatments lead to cognitive changes, similarly cognitive treatments lead to behavioural changes.
- Behavioural activation:
- ~ Techniques include activity scheduling, rehearsing and practising alternative behaviours, therapist modelling, teaching and applying self-reinforcement, skills training.
- ~ Focus on resolving issues in existing relationships and learning to form new interpersonal relationships.
Antidepressants = CBT = IPT > placebo or psychodynamic.
- ~ For severe and non-responsive cases.
- ~ Don't know how it works.
But medication has a higher relapse rate.
BA = CT.
Equally effective, but BA are easier to learn and quicker to implement.
What is dysthymia?
Mild depressive symptoms experienced continuously over a prolonged period.
- DSM criteria:
- ~ Depressed mood most of the day, for more days than not, for at least 2 years.
- ~ 2 or more of: change in appetite, insomnia/hypersomnia, fatigue, low self-esteem, poor concentration, feelings of hopelessness.
Often has early onset (childhood, adolescence of early adulthood) - maybe it is a personality feature?
Onset before 21 associated with increased chronicity, poor prognosis, stronger likelihood of the disorder running in the family.
What is double depression?
- MDD and dysthymia.
- Dysthymia typically precedes MDD.
- Less likely to respond to treatment.
What are the types of bipolar disorder?
- Bipolar I: alternate full manic episodes and depressive episodes.
- Bipolar II: alternate hypomanic episodes and depressive episodes.
- Cyclothymia: alternate dysthymia and hypomanic symptoms.
Bipolar may be a more extreme variant of mood disorders. It is quite common for someone with depression to develop bipolar.
Note: depression and mania may not be opposite ends of the same mood state - mixed manic episode (experience manic symptoms but feel depressed/anxious at the same time).
Note: rapid-cycling specifier - more severe variety, does not respond well to treatment.
What is a manic episode?
- DSM criteria:
- ~ Elevated, expansive or irritable mood lasting 1 week (or any duration if hospitalisation needed)
- ~ 3 or more present of: high self esteem/grandiosity, less need for sleep, talkative +++, flight or ideas, distractibility, decrease in goal directed activity, excessive involvement in pleasurable activities
- ~ Episode severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalisation, or there are psychotic features.
Unipolar mania is rare.
What is a hypomanic episode?
- DSM Criteria:
- ~ Distinct period of persistent, elevated, expansive or irritable mood lasting 4 days.
- ~ Period of abnormal mood accompanied by at least 3 additional symptoms (see manic episode)
- ~ Episode not severe enough to cause marked impairment in social or occupational functioning, nor to necessitate hospitalisation. No psychotic features.
1/3 of cyclothymic cases will develop into full blown bipolar disorder.
Cyclothymia is often not recognised - labelled as moody of high-strung.
Treatment for bipolar disorder?
- Lithium - a mood stabiliser. 30-60% respond well. Approximately 70% relapse. Problem with compliance (they like the manic high).
- Fewer relapses for CT group in a 12 month period.
- Focus on treatment when in euthymic phase (normal). Difficult to work with people while manic.
- CBT can be effective if administered at the right time, in conjunction with medication.
- Psychological interventions to manage interpersonal and practical problems.