PS3112 Clinical Psychology: Depression Lecture (2024) PDF

Year 3: PS3112 Clinical Psychology 1 October 2024 Psychological Understanding and Treatment Depression Dr Aftab Laher Consultant Clinical Psychologist Accredited Cognitive Behavioural Psychotherapist Honorary Lecturer in Clinical Psychology Sch...

Year 3: PS3112 Clinical Psychology 1 October 2024 Psychological Understanding and Treatment Depression Dr Aftab Laher Consultant Clinical Psychologist Accredited Cognitive Behavioural Psychotherapist Honorary Lecturer in Clinical Psychology School of Psychology Looking after yourself (and others) We shall be talking about mental health issues broadly and the human experience of “depression” specifically. Some of the material may be distressing or challenging to you and/ or may have personal resonance. If you experience any distress, or you just need some space, please feel welcome to step out or do whatever feels safe for you. You are also welcome to speak to me afterwards. You can also contact the Student Wellbeing Service(phone: 0116 223 1780; email: [email protected]). Dr Aftab Laher 2024 2  Aims  Explore the nature and construct of “depression”.  Give an overview of classification and clinical diagnosis.  Examine the causes/ theories of depression.  Consider the clinical assessment of depression.  Summarise the psychological treatment approaches to depression.  Focus on adults and Cognitive Behavioural Therapy (CBT)  Encourage you to think critically about how depression has been conceptualised and how it has been clinically categorised and treated. Dr Aftab Laher 2024 3 The Nature of Depression Dr Aftab Laher 2024 4 Depression… “Depression is the most unpleasant thing I have ever experienced... It is that absence of being able to envisage that you will ever be cheerful again. The absence of hope. That very deadened feeling, which is so very different from feeling sad. Sad hurts but it’s a healthy feeling. It is a necessary thing to feel. Depression is very different.” J.K. Rowling “Depression is a prison where you are both the suffering prisoner and the cruel jailer.” Dorothy Rowe “People ask me what depression is like. I tell them it’s a lot like walking down a dark hallway, never really knowing when the light will turn on.” Anon. Dr Aftab Laher 2024 5 Depression…  A clinical syndrome distinct from sadness and includes non-transient depressed mood.  Key themes include: pervasive feelings of loss, emptiness, entrapment/helplessness, worthlessness, and hopelessness.  Impairment in aspects of daily functioning.  Clinical presentation may be ‘masked’ or may vary.  Physiological, emotional, cognitive-motivational, behavioural and social/ interpersonal symptoms and signs which interact.  Importance of validating feelings in context.  Importance of seeing “depression” as a socio-cultural construct. Dr Aftab Laher 2024 6 https://youtu.be/tX8TgVR33KM Dr Aftab Laher 2024 7 https://youtu.be/tX8TgVR33KM Dr Aftab Laher 2024 8 Epidemiology of Depression  280 million people worldwide (WHO, 2023)  5% of adults (4% males & 6% females) at any one point in time.  Lifetime prevalence = 2% - 21% (Gutiérrez-Rojas et al., 2020)  32% prevalence in community samples during COVID-19 pandemic (Dettman et al. 2022)  In primary care 35% - 60% stable recovery; 10-15% chronic (Steinert et al., 2014)  >50% chance of recurrence if one major episode. Dr Aftab Laher 2024 9 Overview of Classification & Diagnosis Dr Aftab Laher 2024 10 Caution!  Diagnostic systems can be helpful but can also be a hinderance to understanding of psychological disorders.  Some contention about how diagnostic categories are developed and how they have been applied.  Criticism of “over-pathologising” or “over-medicalising” psychological disorders.  Neglect of socio-cultural context?  Other approaches such as Power, threat, meaning framework (PTMF) (Johnstone & Boyle 2018) are also worth considering. Dr Aftab Laher 2024 11 Overview of Diagnostic Categories Two main classification systems:  1) The WHO system  International Classification of Diseases (ICD) produced by World Health Organisation (WHO)  ICD-10 published 1992: Chapter 5 - Mental & Behavioural Disorders  ICD-11 now out, available online since 2019: Chapter 6 – Mental, Behavioural or Neurodevelopmental Disorders  2) The DSM system  Diagnostic & Statistical Manual of Mental Disorders (DSM) produced by the American Psychiatric Association (APA) (1980)  DSM-IV-TR (2000-2013)  DSM-5 (2013);  DSM-5-TR (2022) Dr Aftab Laher 2024 12 ICD-11 (2021) Mood Disorders Depressive Disorders Bipolar and Related Disorders Single episode depressive disorder Bipolar type I disorder Recurrent depressive disorder Bipolar type II disorder Dysthymic disorder Cyclothymic disorder Mixed depressive and anxiety disorder Other specified bipolar or related Other specified depressive disorders disorders Depressive disorders, unspecified Bipolar or related disorders, (Premenstrual dysphoric disorder) unspecified Dr Aftab Laher 2024 13 DSM-5-TR (2022) Mood Disorders Depressive Disorders Bipolar and Related Disorders Major Depressive Disorder Bipolar type I disorder Disruptive Mood Dysregulation Bipolar type II disorder Disorder Cyclothymic disorder Persistent Depressive Disorder Substance/ Medication-Induced Bipolar (Dysthymia) Disorder Premenstrual Dysphoric Disorder Bipolar or Related Disorder Due to Substance/ Medication-Induced Another Medical Condition Depressive Disorder Other Specified Bipolar or Related Depressive Disorder Due to Another Disorder Medical Condition Bipolar or related disorders, Other Specified Depressive Disorder unspecified Dr Aftab Laher 2024 14 Major Depressive Disorder Dr Aftab Laher 2024 15 Other Syndromes with Depression  Seasonal affective disorder (SAD)  Psychotic depression  Post-natal depression  Adjustment Disorders (“reactive depression”)  PTSD Dr Aftab Laher 2024 16 Causes & Theories of Depression Dr Aftab Laher 2024 17 Broad Determinants of Depression Socio-cultural context Life events/ stress/ big Life history Multi- changes factorial Personality Conditioning/ learning Drugs/ alcohol Dr Aftab Laher 2024 18 Depression often associated with…  Bereavement – especially complex grief  Relationship difficulties/ separation  Problems at work  Problems with family members  Lack of intimacy/intimate relationship  Isolation  Role change/ loss of identity Dr Aftab Laher 2024 19 Theoretical Approaches  Biological  Behavioural  Personality Factors  Psychodynamic approaches  Attachment theory  Cognitive Models  Interpersonal model Dr Aftab Laher 2024 20 Biological  Twin and family studies – modest heritability  Neurotransmitter imbalances or dysregulation (primarily serotonin and, noradrenaline but also cortisol and dopamine).  Other brain or neuropsychological abnormalities.  Critique? See: Shadrina, M., Bondarenko, E. A., & Slominsky, P. A. (2018). Genetics factors in major depression disease. Frontiers in psychiatry, 9, 334. Dr Aftab Laher 2024 21 Behavioural  Learned helplessness – classical conditioning (Seligman, 1975)  Reduction in positive reinforcers/ increase in negative reinforcers – operant conditioning (Lewinsohn, 1974)  Social learning theory  Formation of “vicious cycles” of behaviour which maintain depression  Critique? Dr Aftab Laher 2024 22 Psychodynamic  Freud (1917) Mourning & Melancholia  Compares depression with grief. o Grief: In consciousness; sadness; rage; anger; no loss of self-esteem. o Depression: May not be aware of loss; rage/ anger and disappointment turned inward; loss of self-esteem (feeling helpless, worthless, inadequate)  Both are painful states of mind  ‘Loss’ is central to both  Idea of “introjection”  Critique? Dr Aftab Laher 2024 23 Later Developments “Neo-Freudian”  A great many schools of psychoanalysis and psychodynamic psychotherapy have developed.  Object Relations Theory – more modern psychodynamic perspective (roots in UK in 1940’s and 50’s). People and relationships represented internally as “objects”.  Depressive vulnerability created by caregivers pushing children towards either excessive independence or excessive reliance on caregiver.  Become depressed when lose important relationship in later life.  Common issue in depression = ‘being deeply angry with someone deeply loved and needed’ (Malan, 1979, p.157)) Dr Aftab Laher 2024 24 Attachment Theory (1)  Modern theory based partly on some psychodynamic ideas developed by John Bowlby, refined by Mary Ainsworth and colleagues.  Attachment: “lasting psychological connectedness between human beings.” (Bowlby 1969)  Child builds internal working models of self and other.  Child depends on primary caregiver to provide a secure caring base – allows child to safely explore but be confident of support.  If receive inadequate care in childhood then: o Builds model of self as inadequate, unlovable etc o Builds model of other as unavailable, hostile etc o Leads to lowering of self-esteem Dr Aftab Laher 2024 25 Attachment Styles Dr Aftab Laher 2024 26 Attachment Theory (2)  Child grows to be an adult.  At times of stress (e.g., loss of close relationship): o Negative internal working models of self and other are still in place and become active. o If feelings of self-worth not strong enough then these models may generalise to life in general. o Depression may be the result. Dr Aftab Laher 2024 27 Cognitive Models  Theory of causal attribution (re-formulated learned helplessness theory) (Abramson, Seligman and Teasdale, 1978) o How the cause of the depression is attributed o Depression more likely if attribution is: 1) internal (vs external); 2) stable (vs. unstable); 3) global (vs specific)  Cognitive-behavioural approach (Beck, 1979) – Greatest evidence base. o Original formulation – emotional difficulties due to problems with thinking and behaviour. o Evolved formulation – recognition of socio-cultural context.  Critique? Dr Aftab Laher 2024 28 Assessment Dr Aftab Laher 2024 29  Assessment  Importance of comprehensive clinical assessment  Clinical interview/ observation  Psychometric questionnaires: e.g. o Patient Health Questionnaire (PHQ-9) o Beck Depression Inventory (BDI-II) o Hospital Anxiety and Depression Scale (HADS)  Information from others (with consent) Dr Aftab Laher 2024 30 Classification of Depression Onset (sudden/ gradual) Severity (mild, moderate, severe) Features (melancholic, catatonic etc.) Duration Course/ recurrence (longitudinal, seasonal, rapid cycling etc.) Dr Aftab Laher 2024 31 Five Core dimensions to consider...  Physiological/ sensations/ physical  Emotional/ subjective feelings  Cognitive/ appraisal/ meaning/ thought processes/ motivation  Behavioural/ activity/ lifestyle  Social/ interpersonal/ environmental Dr Aftab Laher 2024 32 Physiological o Loss of appetite/ overeating o Loss of weight/ weight gain (rapid) o Sleep disturbance (insomnia/ oversleeping) o Fatigue/ loss of energy/ lethargy o Aches/ pains o Marked loss of libido o Slumped posture Dr Aftab Laher 2024 33 Emotional/ Affective  Low/ depressed mood / tearful  Intermittent mania/ hypomania  Emptiness/ numbness  Sense of loss  Anger/ resentment  Anxiety  Shame  Guilt  Anhedonia (difficulty in seeking or feeling pleasure) Dr Aftab Laher 2024 34 Cognitive-Motivational  Negative cognitive triad: o self: worthless, inadequate, defective etc. o world: negative, unsupportive, overwhelming etc. o future: bleak, hopeless etc.  Poor concentration  Forgetfulness  Less sharp/ less creative/ poor decision-making  Things seem pointless  Some ideation about self-harm/ suicide  Negative rumination about symptoms (meta-cognition)  Negative flashforwards  Apathy/ lack of initiative or drive Dr Aftab Laher 2024 35 Behavioural  Lowered activity levels  Give up on hobbies/ enjoyable activities  Avoidance  Self-defeating behaviours  Recklessness  Self-harm  Neglect personal care  Hoarding or getting rid of valued things Dr Aftab Laher 2024 36 Social-Interpersonal  Withdrawal  Disengagement  Loss of social confidence/ skills  Disinhibition  Seek to validate worthlessness  Feeling of not belonging  Rejection Dr Aftab Laher 2024 37 Treatment Dr Aftab Laher 2024 38 Treatment Approaches in Context  Talking Therapy o CBT (and “third-wave” cognitive therapies) o Interpersonal Therapy (IPT) o Behavioural Activation (BA) o Psychodynamic Therapy o Counselling o Problem solving therapy/ solution focussed therapy  Medication  Brain stimulation o Transcranial direct current stimulation (tDCS) o Repetitive transcranial magnetic stimulation (rTMS) o Electroconvulsive therapy (ECT) Dr Aftab Laher 2024 39 CBT... An evidence-based therapy model that validates human responses to life difficulties, but is aimed at identifying, challenging and changing unhelpful patterns of thinking, unhelpful patterns of behaviour, and unhelpful socio- environmental contexts to help manage emotional and physical distress, enhance daily functioning, improve quality of life, and maximise choices and opportunities. Dr Aftab Laher 2024 40 Background and History of CBT  1920s – 1960s: Behavioural theory roots  1960s/ 1970s: Behavioural therapy established  1980s: Cognitive therapy for emotional disorders especially anxiety and depression  Mid 1980s: Application of CBT to physical health conditions, especially pain  1990s: Mushrooming of CBT approaches  2000 onwards: Brief CBT Models; Cognitive change mechanisms; Computerised CBT  2005 onwards: “Third-wave” cognitive therapies; IAPT; Online approaches;  2008 onwards: People with cognitive impairments Dr Aftab Laher 2024 41 Background and History of CBT  Multiple influences  Various interpretation of what CBT is  Not one treatment approach but a broad umbrella for range of ‘cognitive/ behavioural’ approaches  Greater evidence base for Beck’s model of CBT  Has been established as treatment of choice in many mental health and physical health conditions Dr Aftab Laher 2024 42 Broad Aims of CBT  To help the client recognise, understand, challenge, and change the unhelpful (negative) thoughts, beliefs & assumptions, and unhelpful behaviours and interactions that maintain the depressed state, whilst also addressing adverse systemic and contextual factors.  Through cognitive reframing by ‘talking’ and writing (e.g., questioning the evidence and building an alternative understanding).  Through behavioural changes, activity planning and ‘experiments’ (e.g., testing out predictions based on client assumptions).  Through socio-environmental adjustments and re-organising the context (e.g., involving family members to help create safer and compassionate interaction). Dr Aftab Laher 2024 43 Core aspects of CBT Model  Reciprocal interaction and determinism between biological, psychological and social-environmental systems.  The primacy of cognition and appraisal processes - cognitive processes, especially subjective meaning/ appraisal, have an influential role within the CBT context. “It is not things in themselves which disturb us but the view we take of things.” (Epictetus) Dr Aftab Laher 2024 44 We all react differently yet the same… Dr Aftab Laher 2024 45 The Beckian CBT Model SYMPTOMS/ EFFECTS: (physiological, cognitive, emotional, behavioural,) Cognitive (Negative) Automatic thoughts Errors/ Bias Activating events/ critical incidents/ context Safety behaviours Assumptions/ Rules SCHEMA/ Core Beliefs Predisposition (dysfunctional) Early learning Past experience Ongoing learning Dr Aftab Laher 2024 46 Core aspects of the CBT model  Behavioural learning/ conditioning  Three levels of cognition: o Automatic thoughts/ images (immediate/ situational) o Intermediate level thoughts (assumptions/ rules for living/ across situations/) o Core beliefs/ schema level (deeper thoughts about self and the world/ global)  Cognitive and behavioural feedback loops Dr Aftab Laher 2024 47 Behavioural learning  Classical conditioning – learning by association.  Operant conditioning – learning through the consequences of behaviours (i.e., how behaviour is reinforced).  Social learning – learning through observing others; through education; through social transmission and societal/ cultural expectations. Dr Aftab Laher 2024 48  CBT Formulation of Depression Parents not attentive and dismissive of efforts for Early Learning Experience: approval. Depressogenic Schemas/ Assumptions: I am not worth bothering with; I am a failure and second rate Poor assertiveness; Withdrawal from social Depressogenic Behaviours: situations Critical Event (s): Breakdown of relationship It’s all my fault; I can never make a success of Negative Automatic Thoughts: relationships; No-one will ever love me Loss of energy/apathy; Hopelessness; Sleep Symptoms: disturbance Dr Aftab Laher 2024 49 General Assessment Framework DOMAINS TIME FRAME Physical Past experience Emotional Recent triggers COGNITIVE Current maintaining factors Behavioural Social Dr Aftab Laher 2024 50 Summary of Main CBT Treatment Strategies  Physiological Strategies o Breathing and Relaxation  Emotion regulation strategies  Cognitive o COGNITIVE RESTRUCTURING o Attention Diversion/ Distraction Training  Behavioural and Lifestyle Strategies o Contingency Management o Activity scheduling/ Behavioural activation o Stress Management Dr Aftab Laher 2024 51 Cognitive Re-structuring  Initial target on negative automatic thoughts (NATS) or “unhelpful thoughts” o Identify o Challenge o Change  Explore and challenge intermediate thought processes (assumptions of daily living)  Explore how deeper core beliefs (or schema) link with current thoughts and behaviours. Change through deeper reflection Dr Aftab Laher 2024 52 Automatic thought processes Thoughts/ Emotional/ Event or interpretation behavioural Situation reaction Good friend Feel low, rejected, I’m not good cancels cinema enough… angry at last minute Last time I ask her… Something Mild disappointment unexpected Will contact her to must have re-plan come up Dr Aftab Laher 2024 53 Thinking Errors  Black and white thinking (no room for “in between”)  Overgeneralising (one bad thing makes everything bad)  Catastrophising/ magnifying (“It’s a disaster!”)  Personalising (“It’s all my fault...”)  Emotional reasoning (“I feel bad so it must be bad”)  Selective filtering/ ignoring the positives  Labelling (“I’m stupid...”)  Mind reading (“I know by her look that she thinks I’m...”)  Unrealistic/ unfair comparisons (“I could do this before...”)  Jumping to conclusions (“this definitely means...”  Over-demanding (using should, must, ought to)  Self-fulfilling prophecy (“I know I will fail...”) Dr Aftab Laher 2024 54 How CBT Works Sessions 1 and 2  Developing therapeutic alliance  Setting goals  Increasing hope  Clarifying relationship between beliefs, mood and behaviour  Socialising to CBT model  Emphasise importance of homework Dr Aftab Laher 2024 55 Sessions 3 - 10  Sharing your formulation  Activity monitoring and scheduling  Graded task assignments – SMART Goals: Small/ Specific, Measurable, Achievable, Reward, Time  Improve sleeping, eating.  Distraction techniques  Identify cognitive distortions  Modify cognitions and beliefs using thought records and cognitive restructuring: Socratic questioning and downward arrow technique or chaining. Dr Aftab Laher 2024 56 Sessions 11 onwards…  Relapse prevention - Identifying high risk times - How will you know if you’re starting to become depressed again? - What can you do? Dr Aftab Laher 2024 57 Key Aspects and Communication Style in CBT  Holistic/ biopsychosocial  Educational  Individual tailoring  Goal oriented and structured  Active patient participation/ ‘collaborative empiricism’  Guided discovery  Cope/ manage/ build versus cure  Brief/ short-term programme aimed at longer-term coping  Dynamics of therapeutic relationship just as important as techniques Dr Aftab Laher 2024 58 Things that are worth emphasising  Collaborative approach  Need to have/ follow some structure  Need to take ownership  Need to engage/ respond to questions  Intervention will involve ‘doing’ as well as ‘talking’  Homework assignments  Need to have realistic expectations/ goals  Instil hope – opportunity to change ‘pattern’ Dr Aftab Laher 2024 59 Interpersonal Therapy (IPT)  Developed by Gerald Klerman and colleagues 1974  Approach manualized in 1984  Depression best understood as a response to problems with interpersonal relationships and needs  Focuses on difficulties in current interpersonal relationships  Focuses on important (social) life events Dr Aftab Laher 2024 60 Theoretical Background to IPT  Harry Stack Sullivan (1953) – highlighted the link between psychiatric problems and interpersonal problems  John Bowlby (1973) – insecure attachment with a caregiver may lead to vulnerability to psychiatric disorder Dr Aftab Laher 2024 61 IPT…  IPT recognises role of genetic, developmental, and personality factors in depression.  BUT  Focus of therapy is on current interpersonal relations of the depressed person - now and the recent past.  Short-term/time limited approach  Solution-focused Dr Aftab Laher 2024 62 Broad Aims of IPT  ‘Understand’ onset of depression & the fluctuations in depressive symptoms in terms of client’s current interpersonal problems.  Find new ways of dealing with interpersonal problems that seem to drive the depressive symptoms  Helping client develop more effective strategies for dealing with interpersonal problems associated with their depression  Encourage a confidence in dealing with and adapting to these interpersonal problems Dr Aftab Laher 2024 63 IPT focuses on…  Interpersonal disputes  Role transition  Loss/ complicated grief  Interpersonal deficits Dr Aftab Laher 2024 64 How IPT Works  Phase 1 (2-4 sessions) o Explore difficulties o Agree diagnosis/ formulation o Set goals/targets for change o Explain how IPT will work  Phase 2 (4-8 sessions) o Work on solutions o Problem-solving approach  Phase 3 (2-3 sessions) o Prepare for treatment termination o Discuss maintenance plans Dr Aftab Laher 2024 65 Behavioural Activation  A brief, structured, psychosocial therapy – can be delivered standalaone or within CBT.  Developed from behaviour therapy roots, initially by Charles Ferster (1973, 1981) and Peter Lewinsohn and colleagues (Lewinsohn, 1974, Lewinsohn et al., 1984)  Importance of functional analysis – what happens before, during and after  Depression reduces engagement with rewarding behaviours and activities.  In turn, disengagement and avoidance behaviours are negatively reinforced thus fuelling the cycle of depression and inactivity.  Aims to gradually and systematically help client to re-build meaningful engagement and activity and reduce unhelpful behaviours through not being tied to current mood and immediate outcomes. Dr Aftab Laher 2024 66  Behavioural Activation Depression Feel better. Less enjoyment of Enjoyment of life. Low energy and Better energy and life. Social Social interaction. motivation motivation. isolation.. Do less. Stop Graded exposure Anxiety. Low Greater doing things that BA mood. Paralysis. to valued confidence. Sense matter. Procrastination activities. of achievement. Avoidance. Dr Aftab Laher 2024 67  Summary  Depression – not just sadness; a more pervasive feeling of being down, empty, hopeless etc.  Can vary in severity/ frequency/ course.  Some impairment/ interference in functioning.  Fairly prevalent (but some differences in gender/ ages).  Depression is multi-factorial.  Range of talking therapies can help; Most evidence for CBT then IPT/ BA.  Medication and biomedical interventions have a role (especially when depression is more severe or enduring) Dr Aftab Laher 2024 68 “Don’t count the days, make the days count.” Muhammad Ali Dr Aftab Laher 2024 69 Thank you for watching and listening [email protected] Dr Aftab Laher 2024 70