Download Depression

DEPRESSION
Major Depression
“I’ll change my state with any wretch, Thou canst from gaol or dunghill fetch.
My pain’s 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 damn’d 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
self—to the mediating intellect—as 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)
Causes of Disability in the United States, Canada, and Western Europe in 2000
Iglehart, J. K. N Engl J Med 2004;350:507-514
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
Diagnostic Algorithm for Major Depression
Whooley, M. A. et al. N Engl J Med 2000;343:1942-1950
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
“Most Depressed” or
“Least Happy”
State
in terms of combined
per capita rates of
diagnosed depression
and suicide?
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%
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1970 - 66%
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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”
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
disorder
- must have lasted at least 1 month and not
be due to another preexisting mental
Feighner criteria = extraordinarily high reliability rating scores
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 Kramer’s 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
-------------------------------------------------------------Conflating minor depression/dysthymia with major
depression leads to two troublesome outcomes:
(1) social forces are not considered or taken seriously
(2) limits the search for holistic treatment and prevention
Dangers of Over- and Under-Diagnosing
Hans Eysenck’s personality theory (1947)
“Major Depression” and Environmental Stress
“Major Depression” and Environmental Stress
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)
Teens and the Antidepressant Dilemma: “Rollback” Dilemma
The Most Effective Treatment
for Major Severe Depression
Volume 357:1939-1945
Clinical Evidence
November 8, 2007
No. 19
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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.
The New Extreme Form of Treatment for Major
Severe Depression, DBS (Deep Brain Stimulation)
The Futile Pursuit of Happiness: Environmental Stress
Gilbert, Wilson, Loewenstein, & Kahneman:
“We consistently misestimate the intensity and duration
of something’s 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?
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
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)
Newest and Radical Form of Psychotherapy:
“Acceptance and Commitment Therapy”
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