Depression

At least five of the following symptoms must be present for the same two-week period and one of the first two MUST be included in the symptoms

• Depressed most of the day and nearly every day
• Markedly diminished interest or pleasure in activities
• Significant weight loss or gain
• Insomnia or hypersomnia
• Psychometer agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Recurrent thought of death and/or suicide
• Symptoms cause significant impairment in functioning, not due to effects of a substance and are not accounted for by bereavement
•  Affective - Depressed mood, sadness, feeling low                                                                   Behavioural - Social withdrawal, restlessness                                                                   Cognitive - Feeling guilty about any shortcomings of thinking of themselves as worthless     Physical - Changes in sleep pattern, energy levels or appetite

• Most common age of onset = Late adolscence or early adulthood
• Gender most likely to suffer = Women twice as likely
• Why? = Due to various biological and psychosocial reasons: hormones and giving birth
• Longitudinal studies on the length of episodes = Most major depressions usually disappear whether they are treated or not, most individuals recover within a period of 4-6 months 
• Relapse and recurence = Relapse is when symptoms get worse during a period of incomplete or brief recovery, recurrence is a new episode of depressive symptoms following a period of recovery of more than two months
• Three main areas of life that is impaired = Work, parent/child relationships and marital relationships
• Percentage that commit suicide = 10-15%
• Why are they most at risk of dying? = Accidents or other medical problems, less likely to seek treatement or symptoms make them more accident prone

Two major groups of mental illness

• Schizophrenia
• Bipolar

Diagnostic and Statistical Manual of Mental Disorder

• DSM
• 1952 DSM 1
• 'Bible' for American psychiatrists
• DSM-IV-TR 2000

Internal Classification fo Diseases

• ICD
• Published by World Health Organisation (WHO)
• Mental disorders included in 1948 (ICD-6)
• Latest version 1992 (ICD-10) 

• Depression should not be medicalised

All humans have mood levels, natural phenomenon, others suggest mood manifests itself in extreme ways it is a question of degree, low validity

• Coryell et al (1995)

10% people diagnosed with Major depressive disorder go on to develop bipolar episodes, someone with dysthemic disorder can have a major depressive episode, low validity

• How can the presence of a medical condition make diagnosis problematic?

Mood disorder symptoms secondary to effects on brain of medical condition, secondary to effects on brain of drugs used to treat medical conditions, reflective of primary mood disorder unrelated to medical condition, validity - correct diagnosis - appropriate and effective treatments

• GPs diagnosing depression

GPs first recongise symptoms, 3% of UK population treated by GP for depression, poor as 10% suffer, half people who go to GP wiith depressive symptoms are not recongised, low reliability

• Cultural background may make depression more difficult to diagnose 

Culture bias due to Western disagnostic tools, non-western cultures often present with more bodily complaints than subjective distress,  could be mis-interpreted if only western based tools used

• Depression harder to diagnose in men

Less likely to admit to symptoms of depression, more likely to forget previous symptoms, gender bias

• Evaluation

Validity issues

Psychology as a science - not objective, is subjective, no medical/scientific measures, interprets differently which reduces reliability

Ethics - Ethical, non invasive, would be unethical to allow someone to suffer without help, allows person to recieve treatment, imrpove quality of life, unethical as gives a label, wrong diagnosis

• McGuffin et al - Concordance rate of 46% found in MZ twins and 20% found in DZ twins, both rates considerably higher than lifetime risk of developing depression, not 100%, twins share same psychosocial experiences and genetics cannot offer complete explanation. 
• Wendler et al - found that biological relatives 8x more likely to have depression than adoptive relatives.
• Diathesis-stress Model - Having a genetic predisposition for depression will make depression more likely in response to environmental stressors - Incorporates nature and nurture 
• Kendler et al - Provided support for this explanation, found that women who were genetically predisposed to depression were far more likely to to develop depressive symptoms when faced with negative life events

• Neurotransmitters

Depression may be the result of low levels of certain neurotransmitters associated with parts of the brain involved in reward and punishment. Low levels of serotonin and noradrenaline lead to depression

:) Anti-depressent drugs effective treatment for depression, increase noradrenaline and serotonin - supports idea. :) Depression is an unwanted side effect of resperine which reduces levels of noradrenaline which suggests that neurotransmitters could be the cause. :( anti-depressent drugs exert an immediate effect but takes several weeks to start feeling better, extraneous variables :( low levels are an effect rather than a cause

• Hormones

High levels of stress hormone cortisol found in depressed people, when noradrenaline levels are low, hypothalamus loses ability to regulate cortisol levels. Could be a consequence rather than a cause. 10-15% women meet criteria of major depressive after child birth - post natal depression. Speculation that ovarian hormones may play a role but found that  women who experience post-natal depression experience other problems - environmental factors

People who have suffered head injuries or strokes in the frontal lobes of the brain have a strong likelihood of developing depression. This is the part of the brain associated with planning and judgement, emotion and motivation. 

• Starkstein and Robinson

Damage may disrupt noradrenaline and serotonin pathways that connect frontal lobes to other brain structures that regulate mood. This has led to speculation that brain abnormality may be a cause of depression in people who have not suffered from brain damage and brain scans have revealed some frontal lobe abnormality with unipolar disorder

• Lewinson (1974) depression is the result of a reduction of reinforcement. Events such as losing your job induce depression because they reduce the amount of positive reinforcement from others. Depressed people usually become much less socially active. People lacking in social skills the most likely to become depressed because social ineptness will not bring positive reinforcement. However, cause and effect
• Seligman (1975) found that when dogs were restrained and given electric shocks, they failed to initiate escape behaviour when the restraints were removed. Exhibited some of the symptoms of depression found in humans e.g. lethargy, sluggishness. Uncontrollable events - sense of helplessness - depression. Individual gives up trying to influence their environment because they have learned that they are helpless as a consequence of having no control over what happens to them.
• Evaluation: Supports theory as they couldn't get away and gave up trying which lead to depression, ethical because of dogsm reductionist as it simplifies a complex behaviour, determinist as it removes free will, focuses on nurture, psychology as a science. 
• Learned helplessness makes sense in terms of reactive depression (clear cause) however not endogenous depression (no apparent cause). Behavioural Explanation can not explain this, a negative event must occur for depression to develop

• Abramson et al (1978) revised theory and created the hopelessness theory. Aruged that people who attribute failure to internal, stable and global causes more likely to become depressed than those who attribute failure to external, unstable and specific causes. Internal - blame yourself, Stable - things can not change, Global - apply to all situations, External - blame factors outside control, Unstable - Something will not stay the same, Specific - Apply to one scenario.
• Seligman found that if students used internal, stable, global attribution they are more likely to become depressed :)
• Kinderman and Bentall found that questionning on attribution can predict susceptibility to depression :)
• Gotlib and Colby said that attribution could be a symptom rather than a cause of depression :(

• Depression is a grief response to loss that evokes feelings associated with real or imagined loss of affection from the person on whom they was most dependent as a child. Both actual and symbolic losses lead us to re-experience parts of childhood. This explains why depressed people become dependent on others and regress to a childlike state.
• Palosaari and Aro found that children who have lost a parent are particularly susceptible to depression later in life :)
• Parker failed to find such susceptibility :(
• Freud also suggested that unresolved and repressed anger towards parents can cause depression. A person may be unconciously angry towards a parent who has died. When any kind of loss is subsequently experienced, anger is evoked and turned inward on the self. Outward expression of anger is unacceptable to the super-ego. Self-directed hostility may motivate depression and suicide.
• Unfalsifiable, no direct evidence :(
• Depressed people tend to display hostility towards those that are close to them :(
• Mixed evidence for direct link :(
• Cannot be scientifically tested - subjective :(

• Monoamine-Oxidase Inhibitors - Block the enzyme that deactivates noradrenaline and serotonin, less effective than tricyclics when used to treat severe depression, no more effective for mild depression, success rate 50%. Side effects are raised blood pressure, cerebral harmorrhage caused by eating certain foods - pate and cheese.
• Tricyclic Antidepressants - Blocks re-uptake of noradrenaline and serotonin by neurons that released them, effective in treatment of mild and severe depression, best chocie of treatment, 60-65% experience some improvements in symptoms. Toxic effects on cardiovascular system, lethal on overdose, effects aren't felt for 2-3 weeks, 50% relapse.
• Selective Serotonin Reuptake Inhibitors - Blocks the re-uptake of serotonin, Prozac is the wonder drug, almost almost impossible to kill self with overdose, many on prozac have attempted suicide, strange, agitated state of mind that can trigger an unstoppable urge to commit suicide or muder.
• Evaluation Positive - Quicker than talk therapies, cheaper method, more familiar, less stigma attached, effective when compared to placebos, does have an effect on biology.
• Evaluation Negative - Treats the symptoms not the underlying cause, not 100% effective, suggests biology is not the only cause and treatment, people often relapse after drug

• ECT is Electro-convulsive shock therapy
• Patients given a muscle relaxant and sedative, then electrodes are placed on their temple/s and electric current of 70-150 volts is passed through brain for 0.04-1 second. Convulsion lasts around one minute, 2-3 treatmens a week for 3-4 weeks.
• Bilateral = Current passed through both hemispheres
• Unilateral = Current passed through one hemisphere
• Successful for severe depression
• :) Fink found that ECT is 60% effective for severe depression
• :) Janicak found 80% of his patients responded well to ECT
• :) Effect is immediate
• :( Sackheim found a high relapse rate so it is a short term treatment
• :( Major criticism is that they do not know how it works
• 1. Patients see it as a punishment, ECT encourages them to reduce the depressed behaviour
• 2. Works because amnesia accompanies it as a side effect
• 3. Causes biochemical changes

• Freud developed psychoanalysis
• Beginning of the 20th century
• Aim - Enable the person to cope better with inner emotional conflicts that are causing a disturbance
• Purpose - Uncover unconscious conflicts and anxieties that have their origins in the past in  order to to gain insight into the causes of psychological disturbance
• Catharsis - Client is encouraged to work through conflicts by examining and dealing with them in the safety of the consulting room
• Adults better suited because the confusing or traumatic childhood experiences can be better understood with the benefit of adult knowledge
• Free association - Client asked to allow free flow of knowledge, thoughts or images
• Word association - Client responds to particular words with whatever comes to mind
• Dream Interpretation - Client asked to recount dreams and analyst interprets meanings
• Transference - Client redirects feelings towards therapists
• Projective tests - Ink blot and thematic apperception test, used to uncover recurrent themes
• Depressed Patients - Depressed person becomes less dependent on others

Effectiveness

• Eysenck found that in control group 66% improved spontaneously, only 44% of psychoanalysis patients recovered :(
• Bergin found that in Eysenck's control group some were hospitalised, when criteria assessing improvement changed, the psychoanalysis improved to 83%
• Svartberg and Stiles found no significant difference between a control group and a psychoanalysis group :(

Appropriateness

• Timescale and cost - Slower, more effective, may take several months, can cost £80-£100
• Suitability - May not be suitable for depression as they can be too passive to engage with therapy
• Danger of emotional harm - Draw a traumatic childhood experience, more likely to become depressed/sad

• CBT = Cognitive Behavioural Therapy
• Based on Rational-Emotive Behaviour therapy & Beck's Cognitive Therapy
• Aim - Identify the patient's negative & irrational thoughts so they can be replaced with more positive ways of thinking
• Cognitive Element - Identify & change beliefs that contribute to depression, ABC model (Activating event, Beliefs, Consequences) can be used to help patient better see how their faulty cognitives are leading to undesirable thoughts & behaviour
• Behavioural Element - Beliefs are reality tested through experimentation for abnormal behaviour. Behavioural goals set for new rational ways of thinking to be used
• REBT - Clients helped to recognise & question their beliefs, therapists encourage client to ask themselves 'Who has to be perfect?' Therapist teaches client to substitute unrealistic beliefs for more positive ones. Also encouraged to view fauilure as unfortunate rather than a disaster
• Cognitive Behavioural Therapy - Stage 1: Clients draw up schedule of activities & become more active and confident, stage 2: Recognise automatic negative thoughts, record them & bring them to sessions, Stage 3: Clients recognise underlying illogical thought processes that produce negative thoughts, Stage 4: Client changes maladaptive attitudes & tests in real-life situations.

Effectiveness

• Effective for depression, anxiety and sexual disorders. CBT is as effective as antidepressant drugs without the harmful side effects and long term effects as lower relapse rate.  :)
• Therapies are well structured, with clear goals and measurable outcomes :)
• Jarrett et al found that CBT and MAOI antidepressant drugs are equally effective :)
• Hollen et al found the same with Tricyclic antidepressant drugs :)

Difficulty in Evaluating Therapies

• Senra and Ploaino found that each scale gave a different measure of improvement :(

Appropriateness

• Not suitable for patients with rigid attitudees who are resistant to change :(

Appeal of CBT

• CBT attempts to empower the clinets - free will - not determinist

Effectiveness

• Effective for depression, anxiety and sexual disorders. CBT is as effective as antidepressant drugs without the harmful side effects and long term effects as lower relapse rate.  :)
• Therapies are well structured, with clear goals and measurable outcomes :)
• Jarrett et al found that CBT and MAOI antidepressant drugs are equally effective :)
• Hollen et al found the same with Tricyclic antidepressant drugs :)

Difficulty in Evaluating Therapies

• Senra and Ploaino found that each scale gave a different measure of improvement :(

Appropriateness

• Not suitable for patients with rigid attitudees who are resistant to change :(

Appeal of CBT

• CBT attempts to empower the clinets - free will - not determinist