About 1 in 10 Canadians will develop a major depressive disorder in their lifetime. In this webinar, UCalgary scholar Keith Dobson who has helped to pioneer Cognitive Behavioural Therapy (CBT), a treatment for depression now used worldwide, shares insights on depression gained from his decades of research and practice. Watch the full webinar recording at http://www.ucalgary.ca/explore/clinical-depression-what-you-need-know

1. Clinical depression: what you need
to know
Keith Dobson
Professor of Clinical Psychology, Faculty of Arts
University of Calgary
April 13, 2017

2. Keith Dobson
 Professor of clinical
psychology in the Faculty
of Arts
 Head of the Department
of Psychology
 Leads UCalgary’s
Depression Research
Laboratory
 Research interests are in
clinical psychology,
cognitive behaviour
therapy, depression and
psychopathology

3. Goals for today
Information about
• The nature of depression
• Models of depression
• Treatments for depression

4. What is depression?
• A mood
• A symptom
• A syndrome
• clinical depression (also called Major Depression)

5. Symptoms of clinical depression
At least five of the following symptoms for
at least two weeks:
 sad or irritable mood
 decrease in interest of pleasure from usual activities
 changes in appetite or weight change
 disturbed sleep
 changes in activity (speeding up or slowing down)
 fatigue or loss of energy
 feeling guilt, self-blame
 decreased ability to concentrate or make decisions
 thinking about, or planning, suicide or death

6. How common is clinical depression?
 Approximately 2% of women and 1% of men are depressed today, and
about 5% each year
 Approximately 10% of women and 5% of men will be depressed at
sometime in their life
 Women are approximately twice as likely as men to be or become
depressed
 A person who has one episode of depression will, on average, go on to
have 5 or 6 episodes
 First episodes usually appear in adolescence or early adulthood, but can
happen at any age

7. Common associated features of
depression
• School or job performance problems
• Social withdrawal
• Changes in usual behavior
• Alcohol or drug use
• Anxiety disorders

8. Defining stages of depression
Note: severity is defined here in terms of a measure, such as the Beck
Depression Inventory
0
10
20
30
40
50
60D
e
p
r
e
s
s
i
o
n
S
e
v
e
r
i
t
y
Stage of disorder
Depressed
Not Depressed

9. Subtypes of Clinical Depression
Type of Depression Major Feature
Major Depressive Episode (MDE) A single episode of depression
Major Depressive Disorder (MDD) Two or more episodes of depression
MDD with melancholia A dominance of physical symptoms
Dysthymia (Pervasive Depression) Low grade, chronic depression
“Double depression” Dysthymia and MDE/ MDD

10. Subtypes of Clinical Depression
Type of Depression Major Feature
Seasonal Affective Disorder Regular seasonal pattern (usually with onset in
winter months)
Post-partum Depression Onset within two weeks of childbirth. May be
related to hormonal changes
Psychotic Depression MDE or MDD with some loss of contact with
reality
Bipolar depression Also called manic-depression. MDE plus
episodes of agitation or elation (mania)

11. Depression exclusions
 Due to alcohol or other substances
 Due to a medical condition
 Due to bereavement/ grief

12. What depression “is not”
 An incurable illness
 What someone “deserves”
 A sign of weakness, or moral flaw
 “Caused” by any one factor

13. Suicide
 Mental disorders greatly increase the probability of suicide attempt.
• Highest rate is for psychosis; lower for Bipolar disorder; lower for
Major depression
 Risk factors for suicide
• Age – Teenagers, young adults, and people past middle age are
highest risk
• Gender – Women attempt more; Men have higher completion rate
• Race and ethnicity – American Indian and Alaskan Native groups
have highest rates; white men the next highest

14. Issues in suicide
 Themes for those with suicidal preoccupations
 Negative expectations and hopelessness
 Perfectionism
 Life events and suicide
 Stressful life events, especially involving loss, may be
precipitating factors
 Suicide contagion
 Well-known person’s suicide can increase rates in the
short term
 Parasuicide – suicidal behavior that does not result in death

15. Suicide prevention
 Increased awareness of suicidal thinking
 Provision of crisis centers and services (e.g. 911)
 Changing cultural expectations about dealing with the
problem; de-stigmatizing depression and suicide
 “Postvention” programs after suicide helps survivors

16. Warning signs of suicide risk
 Changes in eating and sleeping habits
 Withdrawal from family, friends, and regular activities
 Violent actions, rebellious behaviors, running away
 Increased drug and alcohol use
 Neglect of personal appearance
 Marked personality change
 Somatic complaints (headaches and stomach aches)
 Loss of interest in pleasurable activities
 Inability to tolerate praise or rewards
 “Making up”; giving back borrowed items

17. Risk factors for depression:
The Biopsychosocial Model
Psychological
Risk Factors
Social Risk
Factors
Biological
Risk
Factors

18. Biological factors for depression
 Genetics
 Brain processes (neurotransmission)
 Medical conditions (e.g. Influenza, hepatitis, mononucleosis,
hypothyroidism)
 Hormonal changes (e.g. Post-partum, menstrual,
menopausal)
 Prescription drugs (e.g. anti-anxiety, anti-hypertensives,
steroids)
 Alcohol or drug abuse

19. Neurotransmission

20. PET scans of depression

21. Psychological factors for depression
 Early experiences
• death or absence of a parent
• neglect or abuse
• chronic illness or lengthy hospitalization
 Maternal depression
 Negative thinking styles
• rumination
• self-defeating or distorted thinking
• negative attributions
• personality styles

22.  Negative behavioral styles
• inadequate social skills; assertiveness
• avoidance and withdrawal
 Hassles and major life events
 Inadequate social support
 Living with a depressed person
Social factors for depression

23. Resiliency factors
 Regular lifestyle habits (sleep, exercise, diet)
 Social support
 Early assessment and intervention

24. Treatments for depression
 No one treatment is “the best”
 Most treatments have approximately equal outcomes
 Combining treatments might improve outcomes
 If one treatment doesn’t work, another may
 The earlier depression is treated, the better the outcome

25. Integrative models of depression
 Emphasize the interaction among biological characteristics,
psychological vulnerabilities, and stressful life events or
ongoing stressful life situations
 Emphasize the need for optimal treatment, using
combinations of effective approaches

26. Core beliefs;
assumptions;
schemas
Life events
Distortions;
automatic
thoughts
• Emotions
• Behaviors
Avoidance, withdrawal
Negative emotions and thoughts
Cognitive model of depression

27. Treatments for depression –
drug therapy
For a current set of treatment recommendations, go to the
CANMAT (Canadian Network for Mood and Anxiety
Treatments) Guidelines
(http://www.canmat.org/resources/CANMAT%
20Depression%20Guidelines%202013.pdf)

28. Treatments for depression
Drug Therapy
Antidepressants Examples
Monamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil)
Tranylcypromine (Parnate)
Tricyclics Amitriptyline (Elavil, Levate)
Imipramine (Tofranil, Impril)
Clomipramine (Anafranil)
Selective Serotonin Reuptake Inhibitors Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertrolin (Zoloft)
New Generation MAOIs Moclobemide (Manerix)
Atypical Antidepressants (Examples) Nefazodone (Serzone)
Venlafaxine (Effexor)

29. Treatments for depression:
Other drugs/ medical treatments
 Lithium (Used for Bipolar depression)
 Tranquilizers/ Sedatives
 Antipsychotics (Major tranquilizers)
 Electroconvulsive Therapy (ECT; Shock therapy)

30. Treatments for depression:
Psychotherapy
 Cognitive- Behavioural Therapy (CBT)
 Behavioral Activation (BA)
 Interpersonal Therapy (IPT)
 Family Therapy
 Supportive therapy

31. Treatments for depression:
lifestyle changes
 Physical self-care (e.g., nutrition, sleep habits, exercise)
 Improving social support
 Emotional self-care
 Spiritual searching

32. Type of Therapy Tricyclics SSRIs Cognitive
Therapy
Initial Number 100 100 100
Completing
Therapy
70 80 90
Not Depressed
at end of
Treatment
(67%)
47 54 60
Not Depressed
one year later
24 27 45
The relative success of drug therapy
and psychotherapy
(Based on 100 individuals starting each)

33. 0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
%Survival
Months (following end of active treatment)
Placebo (n=21)
ADM (n=28)
Prior BA (n=27)
Prior CT (n=30)
Relapse Recurrence
Relapse following successful
treatment

34. How does CBT work?
Therapist factors
Client factors
Relationship factors
Intervention factors
Clinical
outcome
Residual
symptoms

35. Moving towards Evidence-based
Practice Guidelines (adapted from
NICE)
Watchful waiting; outpatient information
Self help; minimal CBT care
CBT or medications,
based on preference
CBT and
medications
Consider
Inpatient
Outpatient

36. Models of relapse/
recurrence
Relapse and recurrence can be affected by:
• original risk factors for onset
• “scarring” or increased risk factors
• increased sensitivity to risk factors
• decreased effects of resilience factors
• stress generation

37. Established risk factors for
recurrence (Burcasa & Iacono, 2007)
With Evidence Without evidence
•Number of episodes •Gender
•Severity of prior episodes •Marital status
•Residual symptoms •Socioeconomic status
•Dysthymia (in adults)
•Family history of
psychopathology
•Cognitive styles
•Stressful life events
•Social support is a protective
factor

38. CBT reduces relapse
Reviews (e.g., Hollon, Stewart & Strunk, 2006) suggest that
antidepressant medication, which is for most patients the
usual care, does not significantly affect the risk of relapse
after medication withdrawal.
Study Prior CBT
Continued
Medication
Medication-
Placebo
Hollon, et al.,
2005
30.8% 47.2% 76.2%
Dobson, et al,
2008
29.4% 51.1% 60.6%
In contrast, CBT is associated with reduced rates of relapse. In two
trials, the one year rates of relapse were:

39. MBCT reduces relapse
• Another innovation in relapse of depression has been the development
of Mindfulness-Based Cognitive Therapy (MBCT)
• MBCT is based on the idea that formerly depressed patients have
negative metacognitions about distress and sadness, and that they have
increased risk for depression because they over-attend to, and over-
respond to, negative sensations
• MBCT teaches mindful attention to sensation and experiences, but
acceptance of distress and negative sensations as transitory aspects of life
• MBCT is based on the work of Kabat-Zinn, but has been written into an
8-session program (Segal, Williams & Teasdale, 2002)

40. MBCT reduces relapse
Study TAU Relapse Rate MBCT Relapse Rate
Teasdale, et al.,
2003
66% 37%
Ma & Teasdale,
2004
78%
(ITT; 3+ Episodes)
36%
(ITT: 3+ Episodes)
20%
(ITT; 2 Episodes)
50%
(ITT; 2 Episodes)
20%
(Protocol; 2 Episodes)
25%
(Protocol; 2 Episodes)
MBCT has been evaluated with formerly depressed patients in two
randomized clinical trials, relative to Treatment as Usual (TAU).
One- year relapse rates in these two trials are as follows:

41. Who can provide help?
Type of therapy Provider
Drug therapy G.P./ Psychiatrist
ECT Psychiatrist
Cognitive therapy Psychologist/ some Psychiatrists
Behavior therapy Psychologist/ some Psychiatrists
Interpersonal therapy Psychologist/ some Psychiatrists
Supportive therapy Psychologist/ G.P./ Psychiatrist/
Social worker/ Psychiatric Nurses
Social support Anyone!

42. Living with depression:
what you can do
 Acknowledge that the person is depressed; label the problem
 Recognize that depression affects thinking and behavior
 Do not stigmatize the person
 Have realistic expectations
 Maintain your daily routines as much as possible
 Consider adjusting family responsibilities but do not marginalize the
depressed person
 Don’t take their depression personally
 Include children and extended family (as appropriate) in discussions and
providing support
 Talk to your family member and his/ her physician/ therapist
 Be as supportive and loving as possible
 Allow yourself your own routines; get help when you need it

43. Preventing depression:
what you can do
 Get enough sleep regularly
 Exercise at least three times a week for 30 minutes
 Eat healthy
 Develop good social support

44. Thank you
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