I have only included psychodynamic treatment here. Please add your second psychological treatment to the slide.
Clinical characteristics of depression
What is depression?
• An affective (mood) disorder.
• Characterised by sadness and withdrawal.
• Can range from mild, moderate to very
severe, and can even result in suicide.
• In 2011 6045 suicides in England
• In Europe, around 5% of people suffer from
depression at any one time.
• Nearly everyone suffers from depression at
some point in their lives, so it is very
Two types of depression – unipolar and bipolar.
• We are studying unipolar depression, of
which there are two types:
Major Depressive Disorder (MDD)– severe but
usually short-lived depressive episode. Can
include psychotic symptoms.
Dysthymic Disorder (DD) – less severe, but usually
chronic (very long-lasting). Low mood must
last at least 3 years to be diagnosed.
• There are two manuals used by doctors and psychiatrists to diagnose depression.
• They are the DSM IV (Diagnostic and Statistical Manual: Version 4) and the ICD-10 (International
Classification for Diagnosis: Version 10).
• The DSM is usually used in England, and the ICD in America, but because the ICD is more widely-
used, we will focus on it’s diagnostic criteria.
General criteria which
must be met
2/3 = mild
3/3 = severe
2/7 = mild
3/7 = moderate
4+/7 = severe
Depressive episode lasts
Mood that is abnormal
and lasts most of the day
almost every day
Loss of confidence/ self esteem
The episode cannot be
attributed to substance
abuse or organic illness
Loss of interest or
pleasure in activities that
are normally pleasurable
Unreasonable feelings of guilt
Decreased energy or
Thoughts of death and suicide
Inability to concentrate and
proneness to indecision
Changes to psychomotor activity, e.g.
agitation or lethargy
Change in appetite with weight
Apply knowledge and understanding of models, diagnosis and classification of depression
•Endogenous depression (caused by internal biological mechanisms).
Usually more severe and long lasting
•Reactive depression (caused in response to external mechanism)
•Melancholic symptoms (DSM) or Somatic (ICD) Biological in origin (e.g.
appetite changes, weight loss, constipation, reduced sex drive and early
•Non-melancholic symptoms are psychological in nature (e.g. slowed
•Seasonal affective disorder (SAD) – symptoms occur mainly in the winter
•Brief recurrent depression – the episodes are fairly frequent but of short
Course of the
•Some of the subtypes of depression found in the classification manuals still
•Premenstrual dysphoric disorder (pre menstrual depression) shares some
characteristics of depression but also involves anxiety symptoms and
specific somatic (physical) symptoms.
AO2: Neither of these terms are used in the DSM or ICD
Ao2: Issue with this classification is that most patients with depression suffer from both.
Where do you draw the line between each one?
Melancholic depression is associated with more severe symptoms, poor response to placebo
treatment and good response to ECT.
This suggests that the melancholic category is a valid category although there are issues
with the reliability of the diagnosis.
Ao2: Different courses and types of depression will have different treatments.
AO2: It is included in the appendix of the DSM
The validity of the syndrome is controversial
Lack of reliable signs
– No clear objective measure
– Use of body language
• Who makes the diagnosis
– Psychiatrists are medical doctors
who specialise in psychopathology
– In the UK people who are
depressed go see the GP who can
refer them to a psychiatrist if it is
– It is estimated that 50% of people
showing depressive symptoms
who visit the GP are not
diagnosed with depression.
To make a valid diagnosis rule out other possibilities 1st
• Very similar, but different treatments
• People with depression perform poorly on tasks which require
cognitive functioning. A diagnosis of depression rather than dementia
can sometimes only be confirmed when the individual’s mood
improves and normal cognitive functioning is restored.
• E.g. hyperthyroidism which is when the thyroid doesn’t work properly
can result in depression.
• When treated the depression usually disappears.
• Depression in childhood is Often masked as a conduct disorder
Additional issues in the classification and diagnosis of depression
• Treating depression as a disease
• Dual diagnosis -Often occurs alongside other mental disorders such as schizophrenia, anxiety
disorders, eating disorders and substance abuse. Normally primary condition is
• Gender -Why is depression diagnosis twice as high in females compared to males?
• Socio-cultural background -Higher levels of mental health problems found in minorities.
• Cultural differences -e.g. Eastern view on depression
• Always comes up as 24/25 mark question
• 8/9 marks AO1
• 16 marks A02
What would you write for 16 marks?!
Biological explanations for depression for example genetics and biochemistry
Evidence to suggest that depression has a biological origin
- Physical symptoms - Drug treatments are successful
- Depression runs in families - SAD- linked to serotonin levels
- Similar symptoms across different cultures
Studies first degree relatives with
(parents- siblings- offspring - we share
50% of our genes)
Examines whether other members of the
family also have depression
People with a relative with bipolar are 3x more likely to be
diagnosed with MDD compared to those undiagnosed with uni
polar or bi polar.
Gershon: Rate of 7-30% of depression between first degree
Weissman: If someone has a relative diagnosed with depression
before they turn 20, they are 8x more likely to be diagnosed with
Studies the concordance rates for
depression in MZ and DZ twins . If
depression is biological in cause it would
be expected that there is a HIGHER
CONCORDANCE for depression in MZ
twins than in DZ twins
McGuffin found a 46% concordance rate of depression in MZ
twins verses 20% in DZ twins
(109 pairs, no evidence of the effect of the shared environment)
Bierut: Carried out research on 2662 twins in Australia and found
a concordance of between 36-44% in MZ twins. Although they
claimed environment played a larger role.
(2662 twin pairs in Australia, environment played a larger role)
“Family studies like Gershon’s, and twin
studies like McGuffin’s, can’t say genes
are the only reason for depression,
because they didn’t separate genes from
Wender: Biological relatives were 8 x more likely to have
depression than adoptive parents
AO2: Unclear whether these findings are from genetic influence or shared environment
Family studies often show inconclusive results
AO2: Provides stronger quantitative data compared to family studies.
Still very difficult to disentangle nature/ nurture.
AO2: Best way to disentangle genetic factors from the environment since they study
people brought up away from the influence of their genetic families.
• Genetics is only a risk factor- not 100% concordance rate
• Genes or environment, nature - nurture
• Genetic uncertainty
– There does not appear to be a particular gene which results in depression.
– An abnormality in the 5_HTT gene has been linked with depression
– This gene is responsible for the transmission of the neurochemical
• Diathesis stress model
Biological explanations for depression for example genetics and biochemistry
Initially people to
was caused by low
levels of serotonin
More recent belief
depression is the
result of an overall
Neurotransmitters are chemical
messages in the brain and nervous
system that transmit nerve
impulses from one cell to the next
across the synapse.
1950s: was discovered that
tricyclic drugs were effective in
They work by increasing the
availability neurotransmitters in
the brain called monoamines:
• noradrenaline and
• NB in the functioning of the
limbic system in the brain
(appetite, emotion, etc).
• No abnormality in noradrenaline in post-mortems of depressed patients
• Some abnormality in reserpine (function is to reduce the availability of
• Reserpine is used to treat high blood pressure and has unwanted side effect
of producing depressive symptoms and suicidal tendencies
Mann et al found impaired transmission of serotonin in people with depression.
• May act as the neuromodulator (controller) of a variety of brain systems.
• If serotonin levels are low, activity in other systems is disrupted = depression.
• Prozac is an effective antidepressant which increases the availability or serotonin the
brain, but has no effect on noradrenaline.
• Thought to be involved in depression in old age
• Dopamine content in brain diminishes considerably post 45
• Synthetic drug L-dopa has no antidepressant effect
Hormones Endocrinology is the study of hormones. High levels of cortisol found in those who suffer from depression
Techniques to supress cortisol secretion are successful as a depression treatment.
Over activity of the HPAC stress circuit may lead to depression.
Nemeroff found that those suffering from major depressive disorder suffered from enlarged adrenal glands which was not found
Depression occurs the week prior to menstruation - 25% of women are affected – most do not receive a severe diagnosis. Result
of an oestrogen (high)-progesterone imbalance (low)
Biological rhythms Result of the changes in the number of daylight hours - or too much artificial light.
Thought to be the result of Melatonin – the ‘dracula hormone’ released in dark conditions.
Melatonin slows us down and makes us feel fatigued.
People with SAD are very sensitive to melatonin.
There is some evidence that serotonin and noradrenaline are also linked to SAD.
Lam et al found drug treatments which include serotinin are effective (but do not cure the problem –
depression returns when treatment ends), where as those including noradrenaline are not.
Madden et al reports a significant genetic influence in winter-pattern SAD. Data collected from 4639
twins in Australia via mailed questionnaire.
Special day light
bulbs can now be
can help those
suffering from the
type of depression
Dracula hormone Treatment
AO2 – evaluation
1. Role of neurotransmitters
• Good amount of evidence that supports link between neurotransmitters and
• Reductionist to say that excess or deficit of chemical in brain is cause of depression
• Anti depressant drugs have an immediate effect on neurotransmitter availability but
can take several weeks to have positive effect on mood.
• Alternative theory is that depression may be linked to damaged neurons or BDNF
(brain-derived neurotrophic factor) deficiency.
2. Role of hormones
• Abnormal levels of cortisol suggest depression may the result of over use of the
stress-response system. This is not a consistent finding.
• Research for hormone imbalance theories are inconclusive (Clare 1985)
• Social changes may occur at the same time as hormonal changes
• Hormonal changes may trigger genetic predisposition to depression.
3. Biological factors as predisposing factor
• No definite evidence that biological features are the cause of depression
• Strong support for contributory factor
• Predispose people to depression, but require environmental triggers (diathesis stress
4. Causal relationship
• Depression causes biochemical changes rather than the other way around?
Psychological explanations for depression:
Psychodynamic and diathesis stress model
• Depression occurs when the normal grieving process
following the death of a loved one does not diminish
• Begin to merge emotions to that of the loved one.
• Introjection feelings for loved one are redirected to the
self (.e.g sadness or anger)
• Later Freud realised not everyone who was depressed
had lost a loved one…
• When loss is experienced this leads to anger but
it is turned inwards as it is unacceptable (by
super ego) to express it
• Thus feelings of guilt, unworthiness and despair,
which if intense may lead to suicide
• Can have the same effect as that of loosing a
• E.g. Being fired, breaking up with a partner etc.
• Symbolic losses can be interpreted the same way
as death of a loved one.
• Depression is like grief.
• Freud – symbolic or actual loss may lead to re-
experiencing parts of our childhood leading to
dependency, clinging or regression to a childlike state.
• Freud believed the greater the experience of loss in
childhood the deeper the depression
Relationship with parents
An alternate psychodynamic view relates depression in
adulthood to the individual’s early relationship with parents.
• Hostile feelings towards the parent are introjected to
the self in the form of self-accusation or self-hatred.
• Could be the result of lack of love and care, support and
safety or child abuse.
• Repression of childhood trauma reappears in adulthood
in the form of anxiety disorders or depression.
The effects of separation and loss
• Bowlby (1973) separation or loss of the mother
in early childhood could result in severe
depression in adulthood
• Support for this view is by Hinde (1977) who
examined the effects of separating infant rhesus
monkeys from their mother.
– Both mother and child displayed behaviours similar
to the symptoms of depression in humans
– Unwise to use primates to study human disorders.
• Paykel (1981) reviewed 14 studies and found the
– 7 studies support the hypothesis, 7 studies did not
support the hypothesis.
• Depressed patients often report a parental style
called “affectionless control” (Martin et al. 2004)
• Issues: Falsifiability - difficult to test Freud’s ideas empirically because it
is impossible to demonstrate unconscious motivations or abstract
concepts such as symbolic loss.
• No consistent evidence to suggest that depressed people show more
• If anger is directed inwards we would not expect depressed people to
be hostile to others, but they are.
• The effect of loss of parent does appear to be associated with later
• It has been estimated that fewer then 10% of people who experience
major losses in their early life go on to develop depression (Bonanno,
• However it would be extremely difficult to isolate the separation from
parent from other associated environmental variables such as financial
loss, lack of adequate care, etc
• Family discord and lack of adequate care predispose people to
depression even in families where there is no actual separation (Harris,
Psychological explanations for depression: Psychodynamic & diathesis stress model
No single explanation can account for depression, various
contributory factors towards the disorder.
Underlying genetic predispositions +childhood loss / negative
thinking = depression if activated by the environment.
Considerable evidence that social environment plays an important
role in the development of unipolar depression.
– Culture, gender, work environment, relationships, role
of stressful life events.
Brown and Harris 1978
• Result of a major
study of depression
among housewives in
2 factors contributing
1. Severe life
These had a particularly
strong effect if
vulnerability factors were
a) Lack of paid
b) 2 + children under
c) Early loss of
d) Lack of close
Mazure et al (2000) study on events, personality and depression
• Previous research has shown that stressful life events precipitate episodes of MDD
Q) Why do only some people who experience adverse events go on to develop depression? Becks’
highlighted the role of cognitive personality style.
• Matched pairs (86 participants in total)
• Trained interviewers used standard scales to assess the number, severity and type of stressful events.
• Cognitive personality characteristics were assessed by using Beck’s measures of sociotropy
(Interpersonal dependency) and autonomy (need for independence and control)
• Adverse life events, sociotropy and need for control were significantly related to depressive episode
onset. The type of stressful event also had an impact on the effectiveness of treatment.
• Adverse life events = potent risk factor in predicting depression
• Cognitive- personality factors (e.g. need for control) increase susceptibility to depression
• Interpersonal events (e.g. death of a loved one) has better treatment outcomes compared to
adverse achievement events (e.g loss of job)
• Studies important variables which may influence susceptibility to depression
• However, it did not take into account factors such as social support networks, coping
strategies and early trauma – play a large role in personality style
• Study also found some evidence of gender differences in response to treatment
5 reasons why women are twice as likely to be diagnosed with depression
1. Biological factors
– Evidence shows that hormonal factors in women may result in PMDD, Post-
natal depression and menopause.
– However men suffer from Andropause
2. Poorer quality of life & cultural pressures
– Lower paid and lower status jobs, spill over between job and home, domestic
chores, cultural pressure to be slim, attractive, good wife, mother, etc. These
pressures lead to feeling of inadequacy.
3. Attributional style
– Women are more likely to contribute failures to incompetence compared to
men - linked to depression. (Beyer 1998)
– Women think about what is making them sad more than men.
– These thoughts turn over and over in their minds.
– Rumination is a predictor of depression (Nolen-Hoeksema and Corte 2004)
5. Adverse early life experiences
– Sexual and physical abuse predisposed females to depression in adulthood
– There is no significant relationship between men who suffer from early life
experience and adult depression in males.
– In male adverse experiences were more likely to be expressed through
antisocial behaviour and alcoholism
• Support for life events theory and has been
incorporated into the DSM diagnostic criteria
under Axis IV.
– Does not explain why many patients fail to report
critical life events at the onset of their depression
– Nor why some people have ongoing psychosocial
stressors and yet do not become clinically depressed
Biological therapies are designed to redress the imbalance of biochemicals through drugs, ECT and in rare cases Psychosurgery
effect the nervous
system in different
ways, but they all
Tricyclics (TCAs) Selective serotonin re-
uptake inhibitors (SSRIs)
Blocks the production of
monamine oxidase (an
enzyme) used by the
body to breakdown
as serotonin and
availability of dopamine.
Tofranil operates by
blocking the re-uptake of
serotonin and making more
of the neurotransmitters
Example: prozac acts like
tricyclics but targets
reuptake of serotonin
Most frequent type of
• More effective in
reducing symptoms of
(Jarrett et al 1999)
• Have to stick to a strict
diet regime and avoid
certain foods and
combo can be fatal)
• Recently been introduced
as a skin patch which is
less likely to produce
dangerous food combos.
• Not prescribed as often
• Milder than MAOIs
• Less severe side effects.
• Slower acting – have an immediate
biological effect, but takes at least
10 days to reduce depressive
• Takes about 10 days for the
cells to adapt to the TCA and
begin releasing normal levels
• Need to continue medication after
symptoms have improved due to
50% relapse rate (Montgomery,
• More £ than tricyclics
• Originally thought to have fewer side effects.
• Josepth Wesbecker (1990) whilst staking Prozac
shot 20 people at his former work place before
• 2008 US military using Prozac to treat “stress”
• Less side effects than tricyclics and MAOIs
• Can be used with alcohol
• Do not stop taking suddenly as can lead to
unpleasant symptoms including dizziness, nausea,
lethargy and headaches
• SNRIs (Serotonin & noradrenaline) have more
recently been developed.
• SNRIs are more effective in treating depressive
symptoms but may have more severe side effects
Effective in reducing the
symptoms of depression
• Research shows that
drugs can reduce
symptoms of severe
around 65-75% of
• Compared with only
33% for placebos
Treat the symptom and not the cause:
• Drugs do not necessarily offer a long term
• Symptoms reoccur when drugs are not
• Many psychologists believe that a
biochemical imbalance is the result of
rather than the cause of mental disorders.
• Does not address the cause of the
problem – i.e. why the person became
Combining drugs and psychological treatment
• Some severely depressed people find it difficult
to engage with psychological treatment
• Short courses of antidepressant drugs are helpful
Antidepressants can act as first line of defence to
treat those who are suicidal.
• In this way biological and psychological
treatments can work together
Alternative/ natural drug treatments
• Hypericum – perforatum/ st john’s wart
Sensational and shocking
reports in the press about
one or two individuals does
not constitute evidence for
Biological therapies for depression
MAOIs TCAs SSRIs
ECT: Only used if antidepressant drugs have no effect and if there is a risk that the person
will commit suicide (Mental Health Act 2007)
ECT - The original procedures – less
• used very high currents of electricity
across both hemispheres of the brain
• Severe side effects: memory loss, speech
disorders& irreversible brain damage
ECT - Modern procedure: - Much more
• Patient is given muscle relaxants &
• Unilateral procedure is used
• Administer 70 - 130 volts to the temple
of one side of the head for 0.5 – 5.0
• Induces convulsions for a brief period
• Patient comes round from the
anaesthetic with no recollection of the
• A course normally includes 6 sessions
over a few weeks.
Sackheim (2000) -double blind study 80 depressed patients allocated to:
1. UL ECT with 50% electrical dosages
2. UL ECT with 150 % electrical dosage
3. UL ECT 500 % above seizure threshold
4. BL ECT 150 % above threshold
Depression severity, cognitive functioning and memory for personal
and general knowledge were assessed by trained interviewers before,
during, immediately after and 2 months after course of ECT
• High dosage UL and BL were equally effective.
• Week after treatment BL had greater memory& cognitive functioning
impairment than all UL dosages.
• 2 months after BL had the greatest memory impairment
• 53% of the 62 patients who responded to ECT relapsed regardless of
• UL ECT at high dosage is as effective as high dosage BL but produces
less severe and persistent cognitive effects
• Ethical issues?
Unilateral or bi lateral?
Traditional and modern ECT
AO2: Side effects
When first introduced there were
dangerous side effects including bone
fractures, memory loss and confusion.
There are “no detectable” changes in the
brain structure with newer procedures.
ECT can impair memory – particularly if
bilateral ECT is used.
Works more rapidly than antidepressant
drugs or psychological therapies.
Requires consent from patient or close
ECT has a history of terrible abuse being a
means of punishing or controlling people
in mental hospitals.
Applying an electrical current to the brain
is a frightening and forceful form on
Even with newer techniques there are
still side effects
ECT is very effective in
Studies indicate 60-70%
of depressed people
improve after treatment
(Sackeim et al 2001).
of how ECT reduces
symptoms is not
understood. - Like
banging the sides of a
Likely that it works by
increasing availability of
serotonin in the brain.
It is so invasive it is
difficult to isolate which
element leads to the
AO2: Transcracial Magnetic
A safer alternative?
Stimulates brain cells using
magnetic fields without any direct
contact with the brain.
Painless, does not require the use
of anaesthetics, electrodes or
• Not sure how it works, but it is
thought to increase the
availability of noradrenalin and
• 46% of patients in the ECT group
showed significant improvement
• 44% in the TMS group showed
• ECT group showed signs of
memory impairment - TMS did
Psychological therapies for depression – psychodynamic therapy
• Freud introduced Psychoanalysis in the beginning of the 20th Century. Aim is not to
“cure” or “remove symptoms” as this will not resolve the underlying issue.
• Aim – for person 2 cope better with inner emotional conflicts that cause disturbance.
• The purpose is to discover the unconscious conflicts and anxieties that have their
origins in the past.
• When the conflicts are brought in to consciousness the client is encouraged to work
through them by examining and dealing with them is the a safe environment.
• Confusing experiences from childhood are better understood through adult
• Conducted over a number of years which makes
• More current psychodynamic therapies are
emerging which don’t deal with the past and are
A psychological technique used to re
lieve tension and anxiety by brin
ging repressed feelings and
fears to consciousness
Client asked to allow free flow of emotions,
thoughts, connections, images and express
these in words without censorship these
should reflect the internal dynamic
• Depressed people are 2 withdrawn & fatigued to
deal with demanding therapy sessions.
• People become easily disheartened & drop out of
therapy before it has had any therapeutic effect.
• For suicidal patients it is not an option as the
process is long and slow.
The client has to respond to
particular words with whatever
comes instantly to mind.
The client is asked to recount their dreams
and the analyst helps them to interpret the
• Does it actually work?
• Eysenck (1952) claimed it simply does not work!
• However, there are studies with counter
This occurs when the client redirects
feelings (of hostility)towards the
therapist that are usually
unconsciously directed towards a
significant person in their life
(usually a parent).
Many types of projective tests such as the
Rorschach ink blot and the Thematic
The client is asked to describe what they
see in the ink blot or to tell a story around
AO2: Danger of emotional harm
• Guide a client towards an insight that may prove
emotionally more distressing than the original
• Therapists should never work beyond their
competence in dealing with what may arise in
Catharsis Free association
Word association Dream analysis
Transference Projective tests
AO2: Time scale
AO2: Danger of emotional harm
Difficulties in evaluating the effectiveness of therapy
– What is meant by a cure?
– Corsini and Wedding (1995) claim that “cures” from using
psychotherapy range from 30-60%
– This range depends on what we mean by cure.
– Bolger (1989) concept of “cure” is inappropriate and based on a
model of physical symptoms only.
– Should we assume psychological disorders follow a course
similar to physical diseases?
– The effectiveness is a subjective concept measured only by the
extent to which clients feel that their condition has improved.
– Firstly due to the fact
that treatment can span
several years and the
point at which is
assessed may skew
– The variables being
measured are rather
abstract in nature.
– Wedding (1995)
explains that there are
too many variables
involved to enable a
controlled and statically
valid outcome study –
lack of empirical
– At best we can make
by the client at the
beginning and end of
Comparing research studies gains A02 points
• Bysenck (1952) reviewed 2 outcome studies.
– 66% of control group improved spontaneously
– 44% of psychoanalysis patients improved
– Therefore psychoanalysis does not work
• Bergin (1971)
– Patients in one of the control groups were in fact hospitalized
and those in the other group were being treated by their GP.
– Improvement in 83% of psychoanalysis group
– Improvement in 33% in the control group.