Understanding Depression

• Dr Sarah Tully, a Clinical Lecturer at The University of Manchester and Highly Specialist Clinical Psychologist at Pennine Care NHS Foundation Trust, presents these slides, with thanks to Dr Lydia Pearson.

Learning Outcomes

• Understand a brief introduction to depression.
• Identify factors related to the onset and maintenance of depression.
• Understanding NICE recommended treatments for depression.
• Consider cultural and contextual elements in depression.

Depression Facts and Figures

• Depression is a very common mental health difficulty worldwide.
• In 2018, the World Health Organization stated 300 million people of all ages around the world suffer from depression.
• Depression was the primary driver of disability in 26 countries.
• 10% of people presenting to their GP have depression, according to a 2008 study by King et al.
• The lifetime prevalence rate in the UK is 5% in 2002.
• Depression is the most common mental health difficulty in later life with 10-15% of the population aged 65+ experiencing significant depression in 2003.
• The WHO in 2017, found it is the leading cause of ill health and disability worldwide.
• There are effective treatments.

Symptoms of Major Depression

• Symptoms must be present for at least 2 weeks.
• These symptoms include: depressed mood most of the day, nearly every day, or markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
• In addition to at least three of the following symptoms: significant change in appetite or weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness and/or inappropriate guilt, diminished ability to think or concentrate, and recurrent thoughts of death, suicidal ideation, suicide attempt, or a specific plan for ending one's life.
• This results in distress and/or functional impairment in the person's life (e.g., occupational or social).

Factors Related to Onset & Maintenance

• Biogenetic factors include familial risk, genetic differences in neurotransmitter production/uptake like serotonin, gender/sex, and physical health conditions.
• Sociocultural factors include environmental factors, gender, ethnicity, socioeconomic status, discrimination, and (self)stigma.
• Psychological factors are early & recent trauma, certain schemas & coping styles, rumination, meta-emotion, and gender with women are more likely to present with depression and receive treatment, it is more difficult for men to present with related symptoms.

Serotonin Theory Debate

• The work of Joanna Moncrieff is relevant to the debate about the serotonin theory of depression.
• Evidence was found that depression is not caused by lowered serotonin activity or concentrations.
• Antidepressant medication use is largely based on the serotonin hypothesis.
• Some argue that mental health difficulties have been over-medicalized, rather than understanding the wider context of people's lives and other contributing factors.

NICE Guidelines for Depression in Adults

• Principles of Care: build a trusting relationship, explore treatment choices, and be aware of stigma & discrimination.
• Recognition and Assessment: utilize validated questionnaires to assess the severity of symptoms, previous history, duration, course of illness, impact on functioning, & risk assessment.
• Choice of Treatments: Discuss ideas/preferences and the recommended treatments, how & where they will be delivered.

First-Line Treatments: Less Severe Depression

• Discuss treatment options and match the choice of treatment to clinical needs and preferences.
• Consider the least intrusive and least resource-intensive treatment first, such as guided self-help.
• If the person has a clear preference or experience from previous treatment, support person’s choice, unless are are concerns about suitability for this episode of depression.
• Do not routinely offer antidepressants as a first-line treatment, unless that is the person's preference.

First-Line Treatments: More Severe Depression

• Discuss treatment options with people who have a new episode of more severe depression and match their choice of treatment to their clinical needs and preferences.
• If the person has a clear preference or experience from previous treatment, support person’s choice, unless there are concerns about suitability for this episode of depression.

CBT & BA

• CBT mainly assumes that our thinking is a heavy influence on our behaviour and that this is a symbiotic relationship.
• BA focus on the role that depressed behaviour has in perpetuating the depression through the process of avoidance and behaviour change aims to manage that avoidance.
• The therapeutic intervention thought to successfully improve mood = 'mechanism of change.'
• BA = standalone treatment.

Cognitive Behaviour Therapy (CBT)

• CBT is based on the cognitive model as a framework to understand a person's difficulty.
• CBT focuses on unhelpful thinking & behaviour, how people feel (reactions) is determined by the way they interpret situations.
• It is interpreted via cognition, made up of:
• Core beliefs: are the deepest level of belief and are formed in key developmental years.
• Dysfunctional assumptions: people develop certain assumptions, or rules for living, that help protect them from the activation of their core beliefs.
• Negative automatic thoughts: these are at the top level of cognition and based on the core beliefs when those beliefs are triggered or activated.
• The therapist and client must collaborate to identify and challenge these thoughts to improve reactions.

Longitudinal Formulation

• Looks at early life experience & how it might contribute to difficulties.

Hot Cross Bun Model

• This model is looking at immediate difficulties, rather than at early life experiences.
• Use it with any service user and pick which part to focus on first.

Typical Behavioural Assignments (CBT)

• Activity scheduling involves social activities, self-care activities, exercise, and activities that can bring a sense of pleasure or achievement, especially for depressed clients. -Exposure techniques, especially for anxious clients.
• Interpersonal skills such as social skills, communication skills, and assertiveness skills.
• Emotional regulation such as mindfulness or relaxation techniques.
• Helps people get different solutions to their problems & weigh out the pros & cons and helps with suicidal ideation.
• Techniques to improve sleep, regulate eating, and decrease the use of harmful substances can be used.

Behavioural Activation (BA)

• It is a model of depression based on learning theory.
• A lot of behaviour avoids unpleasant thoughts, feelings, or situations, but tends to miss out on positive reinforcers, especially social ones.
• BA therapy is designed to raise their awareness of this and the unintended consequences of their actions. Rather, client's response to make the situation worse.

Overview of BA

• BA works by targeting the behaviours that maintain depression.
• Cognitions are not targeted, but some ways of thinking might be characterised as behaviour which allows the person to avoid other things.
• Identify goals that are meaningful to the client.
• Activity scheduling with avoided activities, not just the pleasant ones, structuring, social skills training, problem-solving.

Mindfulness

• Mindfulness means paying attention in a particular way, such as giving attention, on purpose, in the present moment, and non-judgmentally.
• Mindfulness => accepting what we've got & taking a step back & letting it go.

Mindfulness-Based Cognitive Therapy for Depression (MBCT)

• NICE recommends group mindfulness for a first episode of less-severe depression.
• Effective for relapse prevention.
• The course is an eight-week group with weekly sessions that are around two hours.
• Helps develop an alternative way of being with experience and to learn skills to more fully engage with present experience to be ‘in the moment'.

Aims of The Mindfulness Course

• Aims of the course include to better understand patterns of recurrent depression, how to 'stabilise attention': to recognise mind wandering and 'autopilot', and how to bring attention back to where we want it to be - with interest, patience, and care, to 'step back' a little from direct experience so that we can see it more clearly, and so choose a kinder response and to build learning into everyday life.
• Each session includes guided meditation exercises, and participants share their reflections on these exercises with the group.
• Personal practice is recommended outside of sessions, including both guided practice and ways to bring mindfulness into everyday life.

Context

• The 'background' to the person's depression.
• It includes individual contexts such as living with domestic abuse or the wider context of where/under what circumstances we live.
• Individual contexts would certainly be important in a psychological formulation.
• However, sometimes criticism is levelled at models informing psychological interventions that they don't always take into account the reality of the world in which a person is living.
• Diagnoses can separate people from the context.

How Does Context Influence Mood?

• Through the impact of appraisals and feelings on mood.

Appraisals include: What beliefs might these environments engender about yourself, the world, and others.

• Key appraisals in depressive disorder.
• If a person is living in a violent or impoverished neighbourhood, this is likely to have an impact on anxiety and depression.
• Psychologists need to consider the wider context and the physical environment of the client.