Lecture 6 - Mood Disorders I.pdf

Mood Disorders I: Depression Geneviève Trudel, PhD Candidate University of Ottawa Reminders • Meeting on the Ph.D. in Clinical Psychology (last meeting) • Thursday 28th at 8:30am; FSS5028 • Midterm questions (DEADLINE OCTOBER 5TH) https://uottawapsy.az1.qualtrics.com/jfe/form /SV_0Vxthdq4U26O9j8...

Mood Disorders I: Depression Geneviève Trudel, PhD Candidate University of Ottawa Reminders • Meeting on the Ph.D. in Clinical Psychology (last meeting) • Thursday 28th at 8:30am; FSS5028 • Midterm questions (DEADLINE OCTOBER 5TH) https://uottawapsy.az1.qualtrics.com/jfe/form /SV_0Vxthdq4U26O9j8 • Class enjoyment : https://uottawapsy.az1.qualtrics.com/jfe/form /SV_6gQonEenriKyGsm Diagnosis? Art Science Providing a diagnosis • After completing an assessment, psychologists generally schedule a feedback meeting to go over the results and communicate diagnoses (if needed) • Feedback is often given collaboratively • Important to give psycho-education about the diagnosis and case conceptualization (including prognosis) • Give clients the chance to ask questions and explore what the diagnosis means for them (and whether it is helpful or not) https://www.youtube.com/watch?v=Ii2FHbtVJzc Diagnosis is a controlled act • Only medical doctors and psychologists can diagnose mental disorders in Ontario • Goldwater Rule (American Psychiatric Association): “On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention…. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.” Summary • Clinical assessments: many different types • Clinical interviews • Differing levels of structures • Psychological testing • Personality, intelligence, neuropsychological, neurophysiological • Diagnosis • DSM-V • Models of diagnosis • Pros/cons of diagnosing mental health problems • Diagnosis as a controlled act Outline • Depressive disorders • Major Depressive Disorder • Persistent Depressive Disorder • Causes and prevalence of depression • Treatment of depression • Cognitive Behavioural Therapy • Specific techniques • Interpersonal Psychotherapy • Medications Mood disorders Mood disorders describe the range of depression (low mood) to mania (excessively elevated mood) Depression Mania Case example: George • George is a 28-year-old who has a successful career in marketing, he has supportive friends and a loving family. • Last year, George’s manager left his position and a new manager started working. George has experienced growing conflict with his new manager. • He reportedly has been feeling sad for several months. He feels that the he little pleasure in life and that activities that used to bring him joy now feel meaningless. • He reports struggling to fall asleep as he often ruminates about work. When he does fall asleep, he reportedly wakes up several times throughout the night. He shares having low energy and feeling fatigue. • He dreads going into work and reportedly can’t concentrate when trying to get things done. • He has diminished appetite and has lost 10lbs since the last few month though he has not made efforts to change his weight. Major Depressive Disorder: DSM-5 Criteria • Criterion A: significant depressive symptoms • Criterion B: significant distress or impairment in social, occupational, or other important areas of functioning • Criterion C: The episode is not caused by the physiological effects of a substance or medical condition • Criterion D: Not better explained by another disorder • Criterion E: There has never been a manic or hypomanic episode What is a mental disorder? • As a general guideline, mental disorders are defined by thoughts, behaviours, and emotions that: 1. Cause dysfunction to daily life 2. Cause personal distress 3. Are atypical or not culturally expected • Each of these elements is insufficient on its own: it is the combination of these factors that characterize mental disorders Major Depressive Disorder: DSM-5 Criteria • Criterion A: significant depressive symptoms • Criterion B: significant distress or impairment in social, occupational, or other important areas of functioning • Criterion C: The episode is not caused by the physiological effects of a substance or medical condition • Criterion D: Not better explained by another disorder • Criterion E: There has never been a manic or hypomanic episode Major Depressive Disorder: DSM-5 Criteria • Criterion A: significant depressive symptoms • Criterion B: significant distress or impairment in social, occupational, or other important areas of functioning • Criterion C: The episode is not caused by the physiological effects of a substance or medical condition • Criterion D: Not better explained by another disorder • Criterion E: There has never been a manic or hypomanic episode Note: Responses to a significant loss … which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered…based on the individual’s history and the cultural norms for the expression of distress in the context of loss Major Depressive Disorder (MDD): DSM-5 Criteria A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (anhedonia) 3. Significant weight loss when not dieting or weight gain 4. Insomnia (limited sleeping) or hypersomnia (oversleeping) nearly every day. 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. There are many ways to meet criteria for MDD 1. Depressed mood most of the day, nearly every day 2. Significant weight gain 3. Hypersomnia 4. Fatigue or loss of energy nearly every day. 5. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day 6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. 1. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 2. Significant weight loss 3. Insomnia 4. Fatigue or loss of energy nearly every day. 5. Diminished ability to think or concentrate, or indecisiveness, nearly every day 6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Prototypical approach to diagnosis: diagnoses require some essential features while also containing flexibility https://www.youtube.com/watch?v=4YhpWZCdiZ c&t=294s&ab_channel=UniversityofNottingham Consider the mental status exam and diagnostic criteria for MDD What are your impressions? Depressive disorder severity • Severity • Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability. • Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning. • Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.” • Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning. MDD Specifiers • Single episode versus recurrent • Individuals with recurrent major depression usually have a family history of depression, unlike people who experience single episodes • Up to 85% of single-episode cases later experience a second episode • Other specifiers (9 in total) • With anxious distress (also considerable symptoms of anxiety without meeting criteria for depression) • With seasonal pattern (commonly known as Seasonal Affective Disorder) • With peripartum onset: before or after giving birth • With psychotic features: negative beliefs can become extreme and delusional and/or hallucinations Persistent Depressive Disorder (Dysthmia) A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating. 2. Insomnia or hypersomnia. 3. Low energy or fatigue. 4. Low self-esteem. 5. Poor concentration or difficulty making decisions. 6. Feelings of hopelessness. C. Criteria for major depressive disorder may be continuously present for 2 years. • Double depression: meeting diagnostic criteria for Major Depressive Disorder AND Persistent Depressive Disorder Of note: no manic symptoms; not better explained by another disorder; not explained by medical condition or substances; distress and dysfunction Persistent Depressive Disorder (Dysthmia) • The prognosis for PDD is often worse than MDD: • higher rates of comorbidity with other mental disorders, • are less responsive to treatment, • show a slower rate of improvement over time • The disorder is (by definition) more entrenched because it is requires 2 years of continuous symptoms (i.e. symptoms are more chronic) Grief and normal sadness • Intense sadness and depressive symptoms after a major loss is normal • Integrated grief: appropriate sadness that re-emerges around key dates, triggers, in addition to ability to remember positives and accept the finality of the loss • Complicated grief: debilitating grief that lasts longer than culturally expected and interferes with functioning • Sometimes caused by an inability to accept the loss • Not a formal DSM-5 diagnosis however added in the DSM-5-TR Prolonged Grief Disorder A. The death, at least 12 months ago, of a person who was close to the bereaved individual B. Since the death (one or both symptoms most days since the last month): 1. Intense yearning/longing for the deceased person 2. Preoccupation with thoughts or memories of the deceased person C. At least 3 of the following symptoms (nearly every day since the last month) 1. identity disruption (e.g., feeling as though part of oneself has died) 2. Marked sense of disbelief about the death 3. Avoidance of reminder that the person is dead 4. Intense emotional pain (e.g., anger, bitterness, sorrow) 5. 6. 7. 8. Difficulty reintegrating into one’s relationship and activities Emotional numbness Feeling that life is meaningless as a result of the death Intense loneliness D. Distress or impairment E. Not culturally expected F. Not better explained by another mental disorder Causes and prevalence Depression is extremely common • Approximately 280 million people in the world have depression (World Health Organization), which is 7x the population of Canada • 16% of the population experience major depressive disorder over a lifetime, and approximately 6% have experienced a major depressive disorder in the last year • Women are about twice as likely to have mood disorders as men • Can occur at any time of life; average age of onset is 25; risk increases dramatically during adolescence • MDD: average duration of the first episode being two to nine months if untreated; probability of remission of the episode within one-year approaches 90% (but remember: single major depressive episodes are rare) • PDD: median duration of approximately five years in adult (can last as long as 30 years) Present moment Birth Psychological factors Depression Social factors Evolution Social, cultural, historical forces Genetics Developmental factors Biological Factors Time Causes of depression Equifinality • Biological factors • • • • Genes (e.g. serotonin transporter) Sleep and circadian rhythms Hormonal system (e.g. hypothyroidism) Physical conditions (e.g., anemia) • Psychosocial factors • Life stressors • Developmental: transitions to new stages of life • Relationship issues • Negative cognitive styles • Social isolation: the risk of depression for people who live alone is almost 80% higher than for people who live with others Life stressor Genetic predisposition Personal loss Depression Case example: George • George is a 28-year-old who has a successful career in marketing, he has supportive friends and a loving family. • Last year, George’s manager left his position and a new manager started working. George has experienced growing conflict with his new manager. • He reportedly has been feeling sad for several months. He feels that the he little pleasure in life and that activities that used to bring him joy now feel meaningless. • He reports struggling to fall asleep as he often ruminates about work. When he does fall asleep, he reportedly wakes up several times throughout the night. He shares having low energy and feeling fatigue. • He dreads going into work and reportedly can’t concentrate when trying to get things done. • He has diminished appetite and has lost 10lbs since the last few month though he has not made efforts to change his weight. Diagnosis Quiz Treatment Stepped care approach to depression: NICE guidelines A CBT approach to depression: George example • Thoughts • Feelings • Behaviours • Physical sensations Three key techniques in CBT 1. Behavioural activation 2. Cognitive restructuring 3. Behavioural experiments Behavioural activation: action before motivation • Engaging in activities before you feel like it • Challenges the behavioural changes in depression (e.g. withdrawing, oversleeping) • Depression thought: “I’ll do activities when I feel better” • Behavioural activation: “I’ll do activities to make myself feel better” • Pleasure activities: anything that provides a sense of joy (e.g. seeing friends, going to the movies) • Mastery activities: anything that provides a sense of accomplishment (e.g. doing chores, working out, going to work) Cognitive restructuring: challenging negative thinking patterns • Specific negative thinking patterns (thinking traps) can be identified and challenged • All-or-nothing thinking: “I’m either a failure or a success” • Discounting the positive: ignoring the positives in a situation or minimizing them • Negative filter: only attending to the negative information • Mindreading: assuming what others other thinking Testing negative beliefs through behavioural experiments • Some beliefs can be tested through experiments • Beliefs that can be tested: “I won’t have any fun if I go out for dinner with my friends” or “I won’t feel better if I go to the gym” • Allows clients to explore whether their predictions about a situation are accurate • Can be done in many ways (testing how behaviours affect mood; surveys to see whether people agree that someone is “a failure”) Interpersonal Psychotherapy (IPT) • Research suggests it is also an effective intervention for depression • Focuses on the way interpersonal relationships affect mood • Types of relationship issues common in depression • Role disputes (e.g. in a romantic relationship) • Adjusting to the loss of a relationship or loss of a role (e.g. after a serious injury) • Adapting to new relationships (e.g. being single) • Learning the social-emotional skills needed for healthy relationships • Types of interventions: • Identifying the key relationships in one’s life (interpersonal inventory) • Identifying the key roles that were in-place prior to the loss and after the loss • Finding strategies to maintain interpersonal roles despite the loss à finding meaning in existing relationships or seeking out new relationships Medications for depression: SSRIs • The most commonly prescribed medications for depression are a drug class called selective-serotonin reuptake inhibitors (SSRIs) • Examples: fluoxetine (Prozac); sertraline (Zoloft); citalopram (Celexa) • Work by inhibiting the reuptake of serotonin in the presynaptic neuron, increasing the supply of serotonin • Common side effects: sexual dysfunctions; gastrointestinal problems • Effective at reducing depressive symptoms Electro-convulsive therapy Light therapy Mindfulness-based cognitive therapy Other treatments (and there are more!) Summary • Depressive disorders • Major Depressive Disorder • Persistent Depressive Disorder • Causes and prevalence of depression • Treatment of depression • Cognitive Behavioural Therapy • Behavioural Activation • Cognitive Restructuring • Behavioural experiments • Interpersonal Psychotherapy • Medications: SSRIs • Other treatments: ECT and mindfulness-based cognitive therapy