Management
Cognitive treatment for depressive disorder
What is the cognitive treatment for depressive disorder?
Cognitive behavioral therapy
Cognitive treatment for depressive disorder
Who and when was it developed?
Beck et al in the 1960s
Cognitive treatment for depressive disorder
What does it combine?
Cognitive and behavioral aspects
Cognitive treatment for depressive disorder
Is it available on the nhs?
Yes
Cognitive treatment for depressive disorder
What is the individual told to focus on and consider?
Focus on negative thoughts and then consider new ways of
thinking
Cognitive treatment for depressive disorder
What are the 2 main focuses on cognitive behavior therapy?
-change distorted
thinking present in those with depressive disorder -train patients to use more
adaptive methods
Cognitive treatment for depressive disorder
What are the 3 main aims of the treatment?
Challenge negative thinking and replace with constructive
positive thoughts that will lead to healthy behaviour -make cognitive errors
conscious and then challenge then, make it look like there is no basis
Cognitive treatment for depressive disorder
When does it usually occur?
Once a week/fortnight for 5 to 20 sessions lasting 50-60
mins
Cognitive treatment for depressive disorder
How does the course normally start?
Education phase, patient taught about relationship between
thoughts, emotions and actions, ethical issues
Cognitive treatment for depressive disorder
Why is an agenda set?
So the client can do what they want at their own pace
Cognitive treatment for depressive disorder
How does therapist help break down problem?
-downward arrow
technique -breaks down into parts that can be connected
Cognitive treatment for depressive disorder
What does it mean by solution based?
Doesn't dwell in the past, all about the here and now, how
thinking is unrealistic
Cognitive treatment for depressive disorder
Why are homework assignments set?
Ao that patient can practice changes talked about, normally
hypothesis testing putting self in situations not normally experience
Cognitive treatment for depressive disorder
What other tools are used for the client outside treatment?
To discover self concept, speaking to friends and family to
find out things about themselves
Cognitive treatment for depressive disorder
What can the therapy help change?
How you think and what you do
Cognitive treatment for depressive disorder
What does the therapy challenge?
Negative thoughts
Cognitive treatment for depressive disorder
What does the therapist summarise at the start?
The agenda to check full understanding
Cognitive treatment for depressive disorder
What is a mood diary, what does it enable to patient to do?
Log and monitor their thought processes outside therapy
Cognitive treatment for depressive disorder
Who is the programme backed up by? (s)
Government funding by the uk
Cognitive treatment for depressive disorder
What is a strength of the stud in terms of time etc?
Fairly quick, cheap to provide and less side effects when
looking at drugs, why the government backs it up
Cognitive treatment for depressive disorder
What did butler conclude? (s)
That cognitive behavior therapy was effective for treating
depressive disorder after reviewing several studies and meta analysis where the
treatment was used
Cognitive treatment for depressive disorder
What did nice find? (s)
It was the most effective treatment in treating severe and
moderate depressive disorder
Cognitive treatment for depressive disorder
What did williams find? (s)
His study is based on cognitive behavior therapy and is our
contemporary study he found that cognitive behavior therapy alone combined with
an imagery treatment was successful in treating depressive disorder of a woman
named carol
Cognitive treatment for depressive disorder
Why is the study ethical?
It has no side effects, so can be regarded more ethical than
the drug treatment
Cognitive treatment for depressive disorder
What belief is cognitive behavior therapy based on and why
might this idea cause a relapse?
It is based on the belief that depressive disorder is caused
by faulty thinking, which might be a result of depressive disorder not a cause,
when depressive disorder is removed so is negative thoughts, shows that
removing cause may not remove the cause, resulting in a relapse
Cognitive treatment for depressive disorder
What are some ethical implications for the treatment? (w)
It essentially blames the person for their disorder as it is
their thoughts that cause it, ethical implication based on how it makes the
patient feel
Cognitive treatment for depressive disorder
What type of data is normally gathered to study the
treatment?
Self report
Cognitive treatment for depressive disorder
Why is the data gathered to study this treatment unreliable
and in valid?
Self report may try to please the clinician and say
treatment is working also may depend on mood which will change day to day
social desirability
Cognitive treatment for depressive disorder
What did chan et al find? (w)
That drug therapy could be useful as an addition to
cognitive behavior therapy and a combination was more effective than cognitive
behavior therapy on its own
Cognitive treatment for depressive disorder
Williams contemporary (icbt and cbm)
What was the aim of the study?
Find out if combined treatment of cognitive biased
modification immediately followed by icbt would be effective in treating
depressive disorder
Where were participants recruited from?
Applied research unit for anxiety and depressive disorder in
Sydney online screenings
How many applied through online screenings?
232
What happened to successful applicants?
They were rang for a diagnostic interview using the mini
What is the mini?
Multi international neuropsychiatric interview
Why were participants excluded?
No internet access, drug abuse and suicidal idealization
How many participants met all inclusion criteria and what
disorder did they have?
69 and major depressive disorder
How many were in the intervention group at the start and
then the finish?
38 and 20
How many were in the control group at the start and finish?
31 and 22
Who many participants were in the baseline questionnaires in
both groups?
I-35 c-28
How long was the treatment?
11 weeks
How long was the cbm?
One week
How long was the icbt?
Ten weeks
What was the criteria for participants?
Had to have major depressive disorder no history of
psychotic mental illness
What age did participants have to be between?
18-65
What was depressive disorder severity measured by?
-beck depressive disorder inventory 2nd edition -phq-9
What were the primary outcome measures?
Severity of depressive disorder distress interpretation bias
What is the phq-9?
Nine item depressive disorder scale of patient health
questionnaire
A recent survey suggested that patients and attendants in the
hospitals face difficulties finding places due to the complexity of the
building structure and the hustle adding to their distress. You have opted to
conduct a study at your hospital to evaluate whether colored hospital map for
healthcare staff to guide patients would help them. What would you measure the
reduction in distress with?
The K10 is a self-report inventory used often as a
simple measure of treatment-outcome for common health conditions, and to
identify need for treatment, or measure psychological distress. It is in the
public domain. It has a five-point Likert scale, options include: all, most,
some, little, to none of the times, scored 5-to-1, respectively. A score of 10
is the minimum for no distress, ranging up to a largest score of 50 for the
most severe distress. For further information on the K10 please refer to
www.crufad.org or Andrews, G Slade, T. Interpreting score on the Kessler
Psychological Distress Scale (K10). Australia and New Zealand Journal of Public
Health: 2001; 25:6: 494-497.
K10
General health questionnaire
Patient health questionnaire
Daily Hassles
State-trait anxiety inventory
What is the k10
Measures distress ten item kestrel psychological distress
scale
How was interpretation bias measured?
Sst
What is the scrambled sentence test?
scrambled sentence test measures interpretation-bias
What were the secondary outcome measures?
Other factors associated with depressive disorder that may
affect treatment such as anxiety
What was anxiety as a second outcome measured by?
Stai-t s
What does the STAI-A help you measure in the evaluation of
patients presenting with excessive stress an worry.
The
State-Trait Anxiety Inventory (STAI) is self-report, a 4-point Likert scale with
40 questions used to measure state anxiety, or anxiety about an event, and
trait-anxiety, individuals with anxiety-personalities. Higher scores correlate
with increased severity of anxiety. Form-Y is Its most recent, available in 40 different
languages. State-trait anxiety inventory-A is the trait version. It helps
assess trait-anxiety, anxiety prone personalities.
Severity of current anxiety
Whether the individual is prone to anxiety
Stress in general adaptation syndrome
Compares state and trait anxiety
It identifies Type-A individuals
What is the CBM?
Computerized training program in which the individuals are presented
with ambiguous scenarios always resolved in a positive manner.
What was the final measure used?
Researchers used their own adapted version of treatment
expectancy and outcomes questionnaire
After intervention group had post scores what happened?
Control group took part
What measure was not carried out in post treatment outcomes?
Interpretation bias
Results: what were there no significant differences in?
Baseline measures pre treatment
What percentage had social phobias in each group? (baseline
measure)
I-34% c-25%
What was found in the treatment expectancy out outcomes
questionnaire?
There were no differences in patients ratings of treatment
expectations
What did intervention group show? (results)
Improvement in scores on all measures
Which group had most improvement?
Intervention group
What were some conclusions?
Combined intervention effective in reducing depressive
symptoms icbm can reduce symptoms in just one week useful to intergrate cbmi
into icbt as a new form of delivery treatment
Why was the internet recruitment a strength? (s)
Allowed to collect a broad sample from all over australia
Why is it useful? (s)
Cognitive behavior therapy was not widely used due to
resources encourages the integration of internet based technologies to treat
depressive disorder
Ethics? (s)
All 69 gave informed consent beforewent through a screening
process to make sure ppts suitable for treatment right to withdraw
Random assignment? (s)
Reduces any bias of ppts characteristics
Reliability?(s)
Easily replicable standardised procedure questionnaires
Use of interviews and questionnaires? (s)
Didn't just reply on one type of data collection method,
increased validity
Self report data? (s)
Quick and easy comparison to be made reduces costs of
manpower needed
Who was the study approved by? (s)
Human rights ethics committee of st vin cents hospital in
sydney
Self report data? (w)
Social desirability lack validity
Cause and effect? (w)
Results could not establish whether change was due to one
programme or both
Generalisability? (w)
Inclusion data 18-65
Validity of withdrawal? (w)
May not have worked on those who withdrew
Long term? (w)
No follow up study so no way to tell may relapse §
What % of people in both groups showed changes?
I - 65% c - 35%
Bio treatment for depressive disorder-drugs
Antidepressants are given to patients on the belief that
depressive disorder is caused by what?
An imbalance of neurotransmitters in the brain
Bio treatment for depressive disorder-drugs
What do antidepressants help to increase?
The levels of monoamine nt in the brain
Bio treatment for depressive disorder-drugs
What effect should antidepressants have?
Restoring the balance of nt and therefore reducing the
symptoms of depressive disorder
Bio treatment for depressive disorder-drugs
What are antidepressants?
Antagonists
Bio treatment for depressive disorder-drugs
How do antagonists work?
By increasing the level of activity, usually by blocking re
up take or by preventing the enzyme that breaks them down in the synapse
Bio treatment for depressive disorder-drugs
Where is the nt available for longer when given drugs?
Synapse
Bio treatment for depressive disorder-drugs
Where does activity increase?
Affected neural pathways
Bio treatment for depressive disorder-drugs
What form do ad take form?
Tablet normally
Bio treatment for depressive disorder-drugs
How long do patients normally take then before feeling an
effect?
7 days
Bio treatment for depressive disorder-drugs
When first prescribed what dosage is given?
The lowest possible thought necessary
Bio treatment for depressive disorder-drugs
How does a doctor decide on which drug to prescribe?
Uses trial and error, prescribes on sees if it works if not
prescribes another
Bio treatment for depressive disorder-drugs
After four weeks and no effect what might the doctor do?
Increase dosage or try alternative medication
Bio treatment for depressive disorder-drugs
How long does a course of treatment usually last?
6 months
Bio treatment for depressive disorder-drugs
Who is given a two year course?
People with a history of depressive disorder
Bio treatment for depressive disorder-drugs
Who is advised to take them indefinitely?
People with recurrent depressive disorder
Bio treatment for depressive disorder-drugs
What does ssri stand for?
Selective seretonin reuptake inhibitors
Bio treatment for depressive disorder-drugs
How do ssris work and is there any side effects?
Normally start by prescribing these safer cause fewer side
effects block reuptake of serotonin less likely serious effects if overdose
Bio treatment for depressive disorder-drugs
What is an example of an ssri?
Fluoxetine
Bio treatment for depressive disorder-drugs
What are moais?
Monomine oxidase inhibitors
Bio treatment for depressive disorder-drugs
How do moais work and is there side effects?
Given as a last resorthave serious side effects stop enzymes
breaking down monamines in synapse have to have strict diet as can react with
certain foods such as cheese and pickles
Bio treatment for depressive disorder-drugs
What percentage of the effect of drugs is placebo effect?
(w)
30-40%
Bio treatment for depressive disorder-drugs
What is the placebo effect a weakness?
Means the drugs don't actually work it is just in the
patients mind
Bio treatment for depressive disorder-drugs
One the drug is stopped, what rates are high? (w)
Recurrence and relapse rates
Bio treatment for depressive disorder-drugs
What does palliative mean?
Relieving pain rather than dealing with the cause
Bio treatment for depressive disorder-drugs
Why are drugs palliative and not curative? (w)
They do not directly cure the disease or target the cause
but relieve some of the symptoms
Bio treatment for depressive disorder-drugs
Are all drugs used for mental health palliative?
Yes
Bio treatment for depressive disorder-drugs
Why is it a weakness if patients reposing well to antidepressants?
They may have to take them indefinitely in order to stop
recurrence
Bio treatment for depressive disorder-drugs
If psychotherapy and other treatments doe not work why is
drugs a strength? (s)
They are the only treatment that will work
Bio treatment for depressive disorder-drugs
What is a weakness in terms of ethics? (w)
Cause serious side effects, especially old fashioned ones,
ssris have been to linked to suicidal ideation in young people
Bio treatment for depressive disorder-drugs
Why are drugs practical? (s)
They are cheaper and can be provided immediately whereas
there is usually a waiting list for other therapies
Bio treatment for depressive disorder-drugs
Why might there be ethical concerns in the patient to doctor
relationship?(w)
Doctor is prescribing the meds so patient may feel like they
have no power and that therefore drugs is there only option as they are just
following what the gp says
Bio treatment for depressive disorder-drugs
What treatment is used when drugs does not work as a last
resort?
Electroconvulsive treatment
Bio treatment for depressive disorder-drugs
Which drugs has been linked to suicidal ideation in young
people?
Ssri
Bio treatment for depressive disorder-drugs
What did pin quart d find?
Reviewed the effectiveness of drug treatment and
psychological treatments and found that psychological treatments were most
effective
Bio treatment for depressive disorder-drugs
EMOTION & THE RELATED DISORDERS
What is mood? Is anxiety a type of mood? Do we separate
pleasure, from euphoria? What is the exact boundary between normal and abnormal
mood? How do we differentiate elation and euphoria? What is dysphoria? What is
sadness, and how it compares to depression in mood disorder? Is there a
difference between mood and affect? What is flattened affect and how does it
differ from apathy? What is inappropriate affect? How does anhedonia differ
from apathy? What is congruence and incongruence of mood? What do we mean by a
labile mood? What is cyclothymic and hyperthymic mood? What is What is the
difference between labile mood and cyclothymic mood. What is alexithymia? What
is dysthymia? How de we differentiate dysthymia, dysphoria, and displeasure? Is
loss of interest different from anhedonia? How do we differentiate between
lability and incontinence of mood? How do we differentiate apathy from
blunting? What is reactive mood and its importance? What exactly are
mood-incongruent delusions and their significance?
What is stress? What is eustress? How eustress differs from
distress? If you are the feeling pressure, are you experiencing stress? How do
we compare trauma and stress?
What is emotion? Is stress an emotion? What is blunting of
emotional responses? What is emotional incontinence?
What
In this section we will cover the concepts and mechanisms of
emotions including normal stress, sadness, pleasure and happiness, worry,
eustress. Then we will describe the abnormal variations like clinical anxiety,
depression, elation, euphoria, euthymia, eustress, distress, pleasure,
dysphoria, anhedonia, and
Major Depressive Disorder
Must last at least 2 weeks At least Five or more symptoms
have been present in the same 2-week period1. Depressed mood most of the day 2.
Markedly diminished in interest of pleasure in all, or almost all activities
most of the day3. Significant weight loss4. Insomnia or hypersomnia everyday5.
Psychomotor agitation or retardation 6. Fatigue or loss of energy7. Feelings of
worthlessness or inappropriate guilt8. Diminished ability to think or concentrate9.
Recurrent thoughts of death, suicidal tendencies with or without a plan Must
cause clinically significant distress or impairment
Mood Disorders
Bipolar I Disorder
Patients with one lifetime Manic episode and patients with
both Manic and Depressive episodes. Patients do not need to have diagnosis of
MDD for Bipolar I
Mood Disorders
Bipolar II Disorder
Patients with Hypomanic episodes and Major Depressive
episode - but never a Manic episode.
Mood Disorders
Mania
A period of abnormally and persistently elevated, expansive
or irritable mood lasting for at least one week or less if a patient must be
hospitalized. Associated with Inflated self-esteem Grandiosity Decrease need
for sleep Distractibility Great physical and mental activity and over-involvement
in pleasurable behavior
Mood Disorders
Hypomania
Hypomanic episode lasts at least 4 days and is like a manic
episode except it does not sufficiently severe to cause impairment in social or
occupational functioning
Mood Disorders
Dysthymia
Characterized by at least 2 years of depressed mood that is
not sufficiently severe to fit the diagnosis of MDD.
Mood Disorders
Cyclothymia
A mild form of Bipolar II disorder. Characterized by at
least 2 years of frequently occurring hypomanic symptoms that cannot fit the
diagnosis of Manic episode and of depressive symptoms that cannot fit the
diagnosis of MDD.
Mood Disorders
Prevalence of Major depressive disorder
5-17% - Has the highest lifetime prevalence of any
psychiatric disorder
Mood Disorders
Prevalence of Bipolar illness
Less than 1 percent
Mood Disorders
Mood Disorders (with Psychotic features)
Significant treatment implications, eg., antipsychotic drugs
along with antidepressants. Distinguished at mood congruent, or mood
incongruent. Mood congruent: in harmony with the disorder, eg., I deserve to be
punished because i am so bad) Mood incongruent: not in harmony with the mood
disorder. - may have schizophrenia or schizoaffective disorder.
Mood Disorders
Mood disorder with Melancholic Features
Used to describe the dark mood of depressive disorder Severe
Anhedonia, early morning wake ups, weight loss, and profound feelings of guilt.
Associated with changes in the autonomic nervous system and in endocrine
functions. Can be applied to MDD, Bipolar I and II Disorder.
Mood Disorders
Mood Disorders with Atypical features
Patients with atypical depressive disorder symptoms include
overeating and oversleeping. Sometimes referred to as, "reversed
vegetative symptoms" and the pattern sometimes called "hysteroid dysphoria"
Typically have a younger age of onset compared to depressive disorder with
typical features,
Mood Disorders
Mood-congruent psychotic symptoms
In harmony with the mood disorder," I deserve to be
punished because I am so bad “typically those with mood-congruent psychoses
have a psychotic type of mood disorder
Mood Disorders
Mood-incongruent psychotic symptoms
Not in harmony with the disorder Delusions or hallucinations
whose content does not involve typical depressive themes of personal
inadequacy, guilt, disease, death, nihilism, or deserved punishment. Typically
have schizoaffective or schizophrenia
Mood Disorders
