DEPRESSION

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DEPRESSION
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Major Depression

• Ill change my state with any wretch, Thou canst
  from gaol or dunghill fetch.
• My pains past cure, another Hell, I may not in
  this torment dwell, Now desperate I hate my
  life, Lend me a halter or a knife.
• All my griefs to this are jolly, Naught so damnd
  as Melancholy.
• Robert Burton, The Anatomy of Melancholy (1621)
• Depression is a disorder of mood, so
  mysteriously painful and elusive in the way it
  becomes known to the selfto the mediating
  intellectas to verge close to being beyond
  description. It thus remains nearly
  incomprehensible to those who have not
  experienced it in its extreme mood, although the
  gloom, the blues which people go through
  occasionally and associate with the general
  hassle of everyday existence are of such
  prevalence that they do give many individuals a
  HINT of the illness in its catastrophic form.
• William Styron,
• Darkness Visible A Memoir of Madness (1990)

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Causes of Disability in the United States,
Canada, and Western Europe in 2000
Iglehart, J. K. N Engl J Med 2004350507-514
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The Birth Growth of Major Depression

• Statistics for Major Depressive Disorder
  (DSM-IV)
• - moderate to severe depression 6.5 community
  prevalence rate
• - lifetime frequency approaches 20
• - 22 of older adults report feeling sad most
  of the day/every day
• We live in an age of melancholy.
• bread and butter of psychiatry, just as
  neurosis was pre-DSM III
• 54 of psychiatric visits and treatment are for
  depression
• 15 are for schizophrenia
• 9 are for anxiety disorders
• 22 are for all else combined

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Diagnostic Algorithm for Major Depression
Whooley, M. A. et al. N Engl J Med
20003431942-1950
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Based on combined per capita rates of diagnosed
depression and suicide, here are the top six
happiest or least depressed states 1.
South Dakota 2. Hawaii 3. New Jersey 4. Iowa
5. Maryland 6. Minnesota
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Most Depressed or Least Happy State in
terms of combined per capita rates of diagnosed
depression and suicide?
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The Birth Growth of Major Depression

• Pre-DSM III term
• melancholia relatively rare and confined to
  mental asylums
• 1917 - 8 of psychiatrists in
  private/outpatient practice
• 1941 - 38
• 1970 - 66
• 1930s-1970s psychiatry shifted its focus to
  psychopathology of daily life / everyday concerns
  (sex, marriage, worldly failure)
• Depression in U.S. dichotomized endogenous or
  reactive
• In Europe endogenous-psychotic or
  neurotic-reactive

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The Birth Growth of Major Depression

• Q Why did this binary view of depression slowly
  die out in the 1970s?
• - clear, distinct boundaries between the 2
  categories hard to find
• - John Feighner at Washington University
  (Feighner criteria 1972)
• 3 criteria - dysphoric mood marked by symptoms
  of being depressed, sad, despondent, hopeless
• - 5 of 7 symptoms from loss of
  appetite, sleep difficulty, loss of energy,
  agitation, loss of interest in usual
  activities, guilt feelings, slow thinking, or
  recurrent suicidal thoughts must be present
• - must have lasted at least 1 month and
  not be due to another preexisting mental
  disorder
• Feighner criteria extraordinarily high
  reliability rating scores

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The Birth Growth of Major Depression

• Other major factors in demise of reactive
  depression
• - psychiatric medications became diagnostic
  splitters
• - modern living vs. hereditary predisposition
  drugs treat both the same
• Peter Kramers Listening to Prozac A
  Psychiatrist Explores
• Antidepressant Drugs and the Remaking of
  the Self (1993)
• - changed what constituted complete
  treatment
• - coincided with rise of managed care/HMOs
• - changed treatment of sub-threshold cases
• - baseline change treatment vs.
  enhancement
• ----------------------------------------------
  ----------------

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Dangers of Over- and Under-Diagnosing

• Hans Eysencks personality theory (1947)

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Major Depression and Environmental Stress
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Major Depression and Environmental Stress
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Teens and the Antidepressant Dilemma
Young people's use of the antidepressants known
as selective serotonin reuptake inhibitors more
than doubled between 1995-96 and 2001-02. That's
based on a database of visits associated with an
SSRI prescription. While only one SSRI drug,
fluoxetine, has FDA approval for use in
adolescents, the data suggests that by 2002 other
SSRIs had taken a larger share of these
prescriptions. Journal of Adolescent Health
(2005)
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Teens and the Antidepressant Dilemma Rollback
Dilemma
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The Most Effective Treatment for Major Severe
Depression
Volume 3571939-1945      November 8, 2007      No. 19

Next    
Clinical Evidence ECT has been reported to result
in a prompt improvement in symptoms of depression
in the majority of patients treated. The
Consortium for Research in ECT (CORE) reported a
75 remission rate among 217 patients who
completed a short course of ECT during an acute
episode of depression, with 65 of patients
having remission by the fourth week of therapy. A
systematic review of six trials involving 256
patients by the UK United Kingdom ECT Review
Group, reported in 2003, showed that the effect
size for ECT was 0.91 (significantly more
effective than sham ECT), and a review of 18
trials involving 1144 patients showed that the
effect size for ECT was 0.80 (more effective than
pharmacotherapy). A meta-analysis showed ECT to
be more effective than antidepressant medications
alone in treating the psychotic subtype of
depression, and it showed a trend for ECT to be
better than combination pharmacotherapy. In a
study involving 253 patients, the CORE group
reported that patients with the psychotic subtype
of depression had higher rates of response to ECT
than patients without psychosis this study also
showed that response rates were higher among the
elderly. The efficacy of ECT is highly dependent
on technique, with remission rates ranging from
20 to more than 80, depending on how the
treatment is performed. Double-blind,
randomized, controlled trials have shown powerful
interactions between electrode placement and
dosage (relative to seizure threshold) in the
efficacy and side effects of ECT. One report
suggests success rates of 30 to 47 for ECT in
community hospitals. These rates have been less
robust than those in clinical trials. This
discrepancy is related in part to coexisting
conditions, but it may also be related to the
tendency to discontinue ECT prematurely, often in
order to mitigate side effects. In this study,
treating psychiatrists often discontinued ECT
before complete remission was achieved.

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The New Extreme Form of Treatment for Major
Severe Depression, DBS (Deep Brain Stimulation)
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The Futile Pursuit of Happiness Environmental
Stress

• Gilbert, Wilson, Loewenstein, Kahneman
• We consistently misestimate the intensity and
  duration
• of somethings utility this is known as the
  impact bias.
• Our ability to predict the emotional consequences
  of a
• decision, purchase, or event is less than we
  think.
• Our mistakes of expectation can lead directly to
  mistakes in choosing what we think will give us
  pleasure. We often miswant.
• Key role of adaptation to good things and
  resilience to bad things.
• our psychological immune system (a sort of
  emotional thermostat)
• e.g., remember when you got your first dial-up
  14,400 baud modem?

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The Tyranny of Choice

• Starter Marriages phenomenon
• Census Bureau 3 million divorced 18-29
  year-olds (1999)
• 253,000 divorced 25-29
  year-olds (1962)
• Atul Gawande, M.D. cancer study
• - 65 of people surveyed say that if they were
  to get cancer, they would want to choose their
  own treatment of those who do get cancer,
  though, only 12 actually want to choose
• Steven Venti, Dartmouth economist Employer 401k
  plans
• The more funds employers offer their employees
  in 401k plans, the less likely the employees are
  to invest in any of them.
• Wine Warehouse vs. Gas Station experiences

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Depression and the Tyranny of Choice

• Excessive choice is often psychologically and
  emotionally burdensome.
• Why?
• (1) Increases burden of information gathering to
  make a wise decision
• (2) Doing all the cost-benefit/expected utility
  calculations is exhausting
• (3) Increases expectations about how good the
  decision will be
• (4) People often assemble an idealistic composite
  of all the options foregone
• (5) Which increases the likelihood that they will
  regret the decision they make
• (6) And increases the chance that they will blame
  themselves when a decision fails to live up to
  expectations (more regret and second-guessing).
• Perhaps colleges/universities offer too many
  choices now, which might help explain double-,
  triple-majoring, etc. (e.g., Spiderbytes)

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Newest and Radical Form of Psychotherapy
Acceptance and Commitment Therapy
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Combating the Paralysis of Choice Cultivating
Contentment

• Helpful countermeasures
• (1) Pro-Actively Limit Choices to 1st order,
  2nd order, 3rd order
• (2) Counterfactual Downward
• (3) Make Some Decisions Nonreversible (e.g.,
  Harvard photography class)
• (4) Anticipate Adaptation
• (5) Learn to Love Constraints (Say No, 1
  major/1minor)
• (6?) Recalibrate expectations, cultivate
  contentment, safety,
• egalitarianism, and a dose of humility