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Understanding Depression: Diagnosis, Assessment, and Treatment
A Self-Study Course by
Thomas Joiner, Ph.D.
Department of Psychology, Florida State University
1 Continuing Education (CE) Credit Hour
Directions: To receive APA approved continuing education credit for this TPA sponsored home study assignment, you must:
1)Read the article in its entirety;
2)Take the test at the end of the article;
3)Mail the test along with $25 (TPA Members) or $100 (Non-TPA Members) to the TPA Central Office at 1011 Meredith Drive, Ste. 4, Austin, TX 78748.
Understanding Depression: Diagnosis, Assessment, and Treatment
Thomas Joiner, Ph.D.
Department of Psychology, Florida State University
I. Goals/Overview
1) Update on latest thinking about the nature and nosology of depression (i.e., the clinical features of depressive disorders; more common in women; prevalence increasing).
2) Survey various interpersonal styles that influence depression and relationships.
3) Provide clinically useful assessment approaches
4) Describe new and usable treatment approaches
II. Descriptive features of depression
A. DSM Depressions
DSM Major Depression
-Anhedonia
-Sadness/irritability-”Motor” Change
-Low Self-Esteem/Guilt-Appetite Change
-Anergia-Sleep Change
-Concentration Difficulty-Suicidality
-One of either anhedonia OR sadness; at least 5 of 9 total.
-Two week minimum (but it can last far longer).
-Over 200 combinations of the 9 symptoms meet for Major Depression-- interesting that 200 people with different constellations of symptoms still viewed as having one disorder; also means that Major Depression is quite variable in terms of its clinical presentation.
DSM Dysthymia and Depressive Disorder NOS
-Dysthymia has a two-year minimum (one year for youth); must have depressed mood (or irritable for youth) more days than not and 2 or more of: appetite change; sleep change; anergia; low self-esteem; concentration difficulty; hopelessness.
-NOS can be assigned for subsyndromal situations where impairment/distress is noteworthy. For example, someone may have all 9 symptoms of DSM Major Depression, and be in acute distress, but only for the last 8 days (doesn’t meet the two week minimum criterion for Major Depression). They should be diagnosed with something though -- NOS is a common choice. Also for times when symptoms have lasted for months or years, have caused considerable distress/impairment, but only 2 such symptoms are present. NOS may be used here as well.
- NOS is not just a “throwaway” diagnosis. For example, it’s been shown that people with “subthreshold” depressive symptoms experience a lot of pain and suffering: high numbers of bed days, high role impairment (roles as spouse, worker, parent, etc.), and high subjective distress.
Bipolar Disorder, Seasonal Affective Disorder, and “Other Depressions”
-Bipolar disorder, also known as manic-depression, is, in general more severe and more rare than major depression (also known as unipolar depression). Bipolar disorder is characterized by episodes of severe depressions, as well as episodes of mania. Manic episodes include grandiose, often delusional ideas, expansive planning, elated mood, boundless energy (e.g., going without sleep for days).
The manic episode presents some interesting clinical dilemmas, because often depressed people who do not have bipolar disorder will describe their non-ill times as “manic” episodes. But when asked about these “episodes,” they are periods of normal functioning (good, stable mood; ideas more or less in tune with reality and loved ones). Clinically, when you see a manic episode, there’s no subtle diagnostic trick to it--it’s very obvious.
One relatively good thing about bipolar disorder is that it is reasonably responsive to medicines, usually Lithium but more and more these days a group of drugs called mood stabilizers (things like Depakote and Valproate). One difficult thing is that some manic patients enjoy their manias, and so getting them to give up the manias (by taking the drugs) is not always easy.
-Seasonal Affective Disorder (SAD) has been well studied by Norm Rosenthal at the NIMH. It’s characterized by major depression symptoms occurring at times of the year when sunlight is less abundant (i.e., in the winter). This disorder is rare in latitudes like Florida’s, because there’s enough light year round. But in more northern latitudes, it can be a problem, the solution to which is light exposure. Light machines are available that patients sit in front of for a couple hours each morning (while they’re reading or something); appears to be effective.
-Other Depressions. It’s important to at least briefly note that symptoms mimicking a depressive episode can occur as a consequence of another medical disorder (e.g., thyroid dysfunction) or as a side effect to some medicines.
B. Differential Diagnosis and Course: Youth Examples
-In kids, how does depression look? It looks similar to in adults, with the possible exception of an irritable/grumpy mood in place of a depressed/hopeless mood.
-In kids, how is depression different from other things, like ADHD? It can be easy to confuse depression and ADHD in kids, because kids in both categories often are a little irritable, have concentration difficulties, and are down on themselves. Some discriminating features: Depressed kids are rarely overactive, whereas ADHD kids often are; depressed kids are rarely over-impulsive, whereas ADHD kids often are; ADHD kids are rarely anhedonic (not getting enjoyment out of things), whereas depressed kids often are; and ADHD is a constant thing that begins early in a child’s life; it stays around at a constant level (unless well treated); whereas depression is a more variable thing, usually starting later in a kid’s life than ADHD, and then coming and going in episodic fashion.
C. Depression as Scourge
-Common: 3-6% current; 10-15% lifetime.
-Increasing on a world-wide basis: This finding comes out of epidemiological research conducted around the world by Weissman, Klerman, and colleagues, and finds that people born in early generations (say, the 20’s) are not as vulnerable to people born later (say, the 50’s), and that the most recent generation is the most depression-prone.
-Persistent: Average episode length is 8 months (same or higher for kids); for dysthymia, it’s greater than 10 YEARS! This an amazing fact about depression; it’s one of the only medical-related disorders you can think of where the acute phase of the problem lasts for weeks, months, and years.
-Recurrent: Single episode--rare or never. The likelihood of having an additional depressive episode after you’ve had a first is at least 50%, probably more like 70%, and some even think it’s 100% (good treatment can probably get this number down; but even good treatment currently can’t get it down toward 0%, unfortunately).
-Painful: Rivals (but does not exceed) heart disease in terms of the impairment (e.g., bed days), social impact (e.g., role impairment), pain (subjective distress), and cost to the health care system.
-Potentially Fatal via suicide
D. Depression in women
-In general, there’s a 2-to-1 gender difference (more women than men get depressed), and the 2-to-1 difference tends to stay around virtually always (e.g., when you look at different SES groups; different ethnicities, and so on).
-Explaining this difference is not easy. Probably not completely hormonal: For example, research shows that there’s not as great an increase in depression at times of hormonal change as we previously expected. Looking at gender differences as they emerge in young kids and adolescents may help explain this.
-There are no gender differences in depression rates in young kids, but, after the age of 15, girls and women are about twice as likely to be depressed as boys and men.
-This appears to be because girls are more likely than boys to carry risk factors for depression even before early adolescence, but these risk factors lead to depression only in the face of challenges that increase in prevalence in early adolescence. Many of these risk factors are psychological in nature.
-Link to eating disorders. Depression and eating disorders often co-occur. Several angles to this:
- Depressed people are extremely body-dissatisfied (i.e., they don’t like their own appearance). Depressed people without bulimia are as body dissatisfied as people with bulimia. Since body dissatisfaction is a risk for developing bulimia, it may further explain why depression and bulimia so commonly occur together.
- Both bulimia and depression are very chronic disorders. It was stated earlier that depression may last for years. The same is true of bulimia. In one study, a group of several hundred women were assessed regarding eating habits and problems, and then were re-assessed 10 years later. Women with eating problems at the earlier assessment were 15 times more likely than other women to have bulimia 10 years later.
III. Assessment
A. The Tripartite Model of Depression and Anxiety
Basic concept is that depression and anxiety overlap considerably, and that the area of overlap consists of general, diffuse negative emotions (feeling “stressed,” upset, and so forth). But, there are areas of differentiation. For depression, this area is anhedonia (not getting enjoyment out of things)--depressed people almost always experience this, and anxious people rarely do (unless co-morbid for depression).
For anxiety, the area of differentiation is called physiological hyperarousal (essentially, how your body acts when in fear; heart palpitations, shortness of breath, break out in a sweat, feelings of choking, numbness, etc.). Anxious people often experience this; depressed people rarely do.
B. Interviewing for depression
In addition to the usual (e.g., a detailed description of the symptoms themselves; a good sense of their course [how they come and go; how long they last]), three things will be emphasized here: 1) a description of a non-depressed “best of times; 2) interpersonal history; and 3) suicide risk.
-Asking about “best of times”
Simply involves some statement like: “All right, now I know about how things go for you when you’re depressed; now I’d like to hear about how you do when you’re not depressed; how do things when you’re at your best?”
Benefits:
1) Gives clinician an idea of just how far therapy might progress (may not be possible to get beyond functioning level of “best of times”). Helps keep therapists’ expectations conservative (not pessimistic, just conservative). Informs realistic goal-setting for patients too.
2) A chance at rapport-building regarding non-threatening material.
3) An opportunity to instill hope; positive emotions like hope facilitate learning and memory, which is useful in many therapies that include “teaching” components”(e.g., cognitive therapy).
-Interpersonal History Survey
Simply involves a statement like: “List all the people in your life, from early on to the present, who have significantly affected you, either positively or negatively. I’ll be writing down the names as you list them.”
[Write down names; also, take note of who is missing: spouse, parent, etc.?]
Then: “OK, let’s go back through the list, and for each person, I want you to answer this question, “What did you get out of the relationship with ______?”
Benefits:
An enormously important contextual variable is whether the depressive symptoms are in response to grief, either about a recent loss or a past one that has not been resolved (and may not be reported by the patient). Unless specifically investigated, you may not know you’re dealing with a grief-related depression. There are different therapeutic tasks for grief- and non-grief depressions, so the distinction matters.
Patients may experience this exercise, in itself, as therapeutic.
Relatedly, also gives lovely data on recurrent relationship patterns which have presented difficulties for the patients and which may come up in the therapist-patient relationship.
-A Suicide Assessment Routine (this is laid out on next page)
Two Most Important Areas: History of Previous Attempt and Nature of Current Suicidal Symptoms
Regarding History of Previous Attempts, evidence is that people who have a history of 0 or 1 previous attempt(s) are just in a different risk category than people who have 2 or more attempts. Regardless of all the other things going on, this one variable tells you a lot about risk. The multiple attempters are virtually always in a higher risk category than their counterparts with 0 or even 1 previous attempt.
Regarding nature of current suicidal symptoms, two concepts are important. The first is termed Resolved Plans & Preparation (Developed Plan for Suicide, Sense of Courage & Competence to Commit Suicide, Opportunity, Intensity/Duration of Ideation)
The other concept is termed Suicidal Desire & Ideation (Frequency of Ideas, Desire for Death, and so on).
Both of these concepts represent serious things, but relatively speaking, the Resolved Plans & Preparation symptoms are more dangerous than the Suicidal Desire & Ideation factor.
Other Risk Factors (e.g., Substance Abuse, Marked Impulsivity, Personality Disorder, Marked Hopelessness, Marked Loneliness, Impaired Health, Recent and Relatively Severe Negative Events, and so on) Are Interpreted In Light of Two Main Areas Assessment--see Suicide Assessment Decision Tree (next page)
Note: “Other significant finding” means the “laundry list” of suicide risk factors, things like severe recent negative life events, marked hopelessness, deteriorating health, loneliness, and so on.
-Suicide-Related Writing: Not Necessarily a Bad Thing
People who do write about suicide (even preparing a potential suicide note) appear to score low on Resolved Plans & Preparation, perhaps because the writing has taken some of the edge off the pain, given time for reflection, reminded them of social support, and so on. Journaling about traumatic feelings and experiences does seem to help -- people who do this derive a physical benefit (better immune functioning) as well as a psychological benefit (less emotional distress in the long-term, although they have a little more distress while they’re actually revisiting the traumatic experience).
-Assessment--Summary
After about two sessions, then, information is available on: a) diagnosis; b) details of symptoms, course, functioning, “best times;” c) goals for restored functioning; d) suicidality; e) interpersonal history; f) possibility of unresolved grief
-And: a) some rapport is built; b) some hope instilled; c) some therapy already done
-Not bad for two sessions (sometimes one). Managed care providers would love this pace!
IV. Interpersonal Features of Depression
There are at least two interpersonal feature of depression that should be emphasized, because they appear to affect treatment outcome and quality of life.
The two features are:
-Excessive Reassurance-Seeking--Tendency to excessively depend on others for sense of worth and security; and
-Negative Feedback-Seeking--Tendency to actively solicit negative reactions from others. Why would people do this? The theory is that the motive to confirm your self-view is so powerful that people will act to do it even if your self-view is negative.
An example of what is meant by Negative Feedback-Seeking:
Patient: ... I did bad things as a kid; never been a nice person; there’s nothing nice about me.
Therapist: Hmm... (doubtful look)
Patient: It’s true; it is true.
Therapist: I’m not sure I see it.
Patient: People don’t think I’m good; only those who can tolerate a lot like me. This is true.
Therapist: Still not sure I see it.
Patient: Well, perhaps you will... you know, there is no need to make me feel better; I just want you to be honest.
The patient here is insistent and persistent that the therapist confirm her negative self-view.
- Depressed people may get “Caught In The Crossfire” Between These Two Tendencies
They simultaneously need contradictory things -- they need a form of positive feedback (reassurance) and they need negative feedback; asking for both is bewildering and frustrating to everyone involved, especially if constantly repeated, so relationships deteriorate, which worsens depression and heightens risk for relapse.
V. Treatment of depression
- Why Systematize or Manualize a Treatment?
-Demonstrated Efficacy
-Focus for Patient and Therapist
-Relief for Therapist from Role of Existential Philosopher, Magical Healer, Proselytizer, etc.
-Managed Care Likes It
- Treatment--Brief notes on antidepressant medicines
The old class of antidepressants (called tricyclics, an example of which is Imipramine) had demonstrated effectiveness, but sometimes substantial side effects (dry mouth, constipation, etc.). These drugs worked by enhancing the functioning of several neurotransmitter systems in the brain. They are lethal in overdose.
A newer class called selective serotonin reuptake inhibitors (SSRIs, examples of which are Prozac and Zoloft) are equal in effectiveness to the old tricyclics, but have a more comfortable side effect profile. They work by keeping as much serotonin as possible “in play” in synapses between neurons. The drugs inhibit the mechanism that “vacuums up” serotonin from the synapse. They tend not to be lethal in overdose.
Length of treatment for antidepressant medicines: Consensus is that, following good treatment response, meds should be continued for an additional 6 to 9 months (longer if patient has severe past history). Disadvantages, of course, include cost and side effects, but these are probably worth it considering that stopping meds early is clearly associated with relapse.
Regarding antidepressant medicines for pregnant women and nursing mothers, the consensus appears to be that these treatments should not be ruled out, in that what data are currently available show no relation between taking SSRIs and fetal abnormalities. (Metabolites do appear in breast milk). Obviously, caution is warranted, but a good case can be made that, if one has the choice between: a) being the mother of an infant while simultaneously being in a Major Depressive Episode; or b) taking an antidepressant while pregnant or nursing, one should choose “b.”
- Treatment--Brief Sketch of Interpersonal Psychotherapy (especially Grief module); see work by Klerman, Weissman and colleagues.