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Lecture 3 SS2023
Lecture 3 SS2023
Health Psychology
Univ.- Prof. Dr. Heather Foran
Summer semester 2023
Outline
• Definition of depression and epidemiology
• Common treatments and their efficacies
• International and national treatment guidelines
• Public health implications, intersections with
health psychology practice
2
Major Depressive Episode
3
Persistent Depressive Disorder (DSM-5)
• Depressed mood for most of the day, for more days than not, for at
least 2 years
• 2 or more of the following
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty with decisions
6. Feelings of hopelessness
4
Prevalence and Course
• Relationship status
• 3 times as likely if not married
• Gender
• 2 times as likely among women (Bromet et al. 2011)
• Differences emerge during adolescence (Petersen et al.,
1991)
• Postpartum depression affects 16% of women (O’Hara &
McCabe, 2012)
• Income and Employment
• Among poor, 2 times as likely
• Among unemployed in Germany 20% (Jacobi et al. 2004)
6
Detrimental Impacts of Depression
7
Comorbidities
8
Multimorbidities: Depression and Physical
Health
• Multimorbidity is defined as 2 or more chronic conditions
• Depression is associated with increased health problems when
examined for 1, 2, 3 or 4 more physical health conditions (Stubbs et
al. 2017)
• This was found in a recent study of 43 countries.
• The odds ratio across studies was 3.3 for multimorbidity of
depression and physical health conditions in low and middle income
countries.
• Other review found 2 to 3 times more likely to have depression in
people with multimorbidity compared to those with no chronic
physical health condition (Read et al. 2017)
• Also increases health care costs and utilization → recommendation
more integrated care (e.g., primary care and mental health care)
Soley-Bori et al., 2021
9
Biopsychosocial Model of Depression
Gene-environmental interactions
Neurotransmitter deficits
Impaired regulation of neural systems
Early history of trauma Depression
Certain cognitive styles
Lack of behavioral reinforcers
Impaired interpersonal relationships
Loss
Other mental disorders (e.g., anxiety)
Other psychosocial factors (job loss)
Chronic pain and physical illnesses
10
Prevention of Depression via Reducing
Maltreatment (Li et al. 2016, Psychological Medicine)
A 10-25% reduction in
maltreatment → 31 to 80
million cases of depression
worldwide
11
Aversive childhood experiences and risk for
Depression
• Child maltreatment increases risk for poor health outcomes
• Including:
• Depression
• Drug and alcohol abuse
• Anxiety
• Eating disorders
• Suicide
• Post-traumatic stress disorder
• Adult Relationship difficulties
• Low health-related quality of life
• The lifetime prevalence of depression is related to the number of
aversive childhood experiences in a dose-dependent manner
• Odds ratio of depression when ACE score is 0 = 1 (no increased risk)
• Odds ratio of depression when ACE score is 3 =3.0 (2.4 – 3.7 CI)
• Odds ratio of depression when ACE score is 2 =1.8 (1.5 – 2.2 CI)
13
Common Antidepressant Medication (ADM)
Types
First generation ADMs Second generation ADMs
Bupropion (Atypical
Antidepressant) 14
Antidepressant medications (ADM)
Fluoxetin (Fluctin)
Sertralin (Zoloft)
Paroxetin (Seroxat)
Citalopram (Cipramil)
15
ADM common side effects
• Sexual dysfunctions
• Weight gain
• Gastrointestinal symptoms
• Sleep disturbances
• Suicide risk for those under 24
• Largely contraindicated for pregnant women
16
Treatments for Depression
Randomized Controlled Trials
versus
17
Study Design
18
Scoring Severity of Depression on the
Hamilton Rating Scale (HAM-D)
• Normal = 0-7 (Remission status)
• Mild depression = 8-13
• Moderate depression = 14-18
• Severe depression = 19-22
• Very severe depression ≥ 23
Mild - 10%
Moderate - 38%
Severe - 39%
Very Severe -13%
19
Clinical Trial Database
• Publically available since 2000, expanded after 2007 law with more
data available since 2008
20
Other clinical trial databases
21
Steps in Clinical Trial Disclosure
Before Study Starts
During Study
• Updates to registry
• Reporting of Results
http://www.clinicaltrials.gov/ct2/results/map/image?term=depression
23
Depression
24
Clinical Trial Database
• Europe
• 546 studies in DE→ now 1407
• 109 studies in AT→ now 333
• Value
• Research ethics
• Scientific progress
http://www.clinicaltrials.gov/ct2/results/map?term=depression&map=EU 25
Meta-Analyses of RCTs: Antidepressants
versus Placebos
• Studies have analyzed the FDA database of all registered drug trials and re-
analyzed raw data of aggregate studies.
• Turner et al. 2008, New England Journal of Medicine
• N = 12,564 patients in the FDA database, 74 trials
100%
90%
80%
70%
60%
30%
20%
10%
0%
Published literature Total FDA databasae
26
Effect Size Measurement
• Cohen’s d
• .2 considered small effect
• .5 considered medium effect
• .8 considered large effect
27
Fournier et al. 2010, JAMA
0,4
0,35
0,3
0,25
Small 0,2
Effect
0,15
0,1
0,05
0
Mild to Moderate Severe Very Severe
28
Severity of Depression
Mild - 10%
Moderate - 38%
Severe - 39%
29
New Study just Published 2018….
„Antidepressant drugs do work, review on almost 120,000 patients concludes
Effectiveness of 21 drugs varies widely, but all were more effective than placebo“
Thomson Reuters · Posted: Feb 22, 2018 10:58 AM ET | Last Updated: Feb. 22
http://www.cbc.ca/news/health/antidepressants-meta-analysis-
1.4546709
30
Cipriani et al. 2018; Lancet
31
Searching process, some examples
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889788/
32
Conflict of Interest Statement for this Paper
• Declaration of interests
• ACi is supported by the National Institute for Health Research (NIHR)
Oxford Cognitive Health Clinical Research Facility. TAF has received
lecture fees from Eli Lilly, Janssen, Meiji, Mitsubishi-Tanabe, Merck
Sharp & Dohme, and Pfizer; consultancy fees from Takeda Science
Foundation; and research support from Mochida and Mitsubishi-
Tanabe. SL has received honoraria for consulting from LB Pharma,
Lundbeck, Otsuka, TEVA, Geodon Richter, Recordati, LTS Lohmann,
and Boehringer Ingelheim; and for lectures from Janssen, Lilly,
Lundbeck, Otsuka, SanofiAventis, and Servier. NT has received lecture
fees from Otsuka and Meiji. YH has received lecture fees from
Yoshitomi. JRG is an NIHR Senior Investigator. All other authors
declare no competing interests.
33
Strengths
34
Study Limitations
35
New ADM for Postpartum Depression?
https://www.vox.com/science-and-health/2019/3/20/18274133/postpartum-
depression-sage-therapeutics-brexanolone
36
FDA approved this “Zulresso”
• https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm633919.htm?utm_campaign=FDA%20approves%20first%2
0treatment%20for%20post-partum%20depression-%20Drug%20Information&utm_medium=email&utm_source=Eloqua
37
What is the evidence?
• Three trials
• Trial one (21 women with severe postpartum depression, HAM-D >=
26)
• Randomized to placebo or drug (Brexanolone)
• Follow up at 30 days
https://www.uptodate.com/contents/severe-postpartum-unipolar-major-depression-treatment/abstract/43
38
What is the evidence?
• Next studies:
• N = 138 and N = 108 and N =21 (3 trials, N = 267 in total; Zheng et al.
2019)
• https://clinicaltrials.gov/ct2/show/NCT02942004
• https://clinicaltrials.gov/ct2/show/NCT02942017
39
Effectiveness Trial – STAR*D
40
Effectiveness Trial – STAR*D
• Did not find a lot of differences in responsiveness to one ADM versus
another
• In ADM trials, remission rates are typically 35% to 45%, so remission
after 1 trial was lower than expected
41
Antidepressant Medications
•Long-term Effects
• In STAR*D trial, relapse was over 40% of those
who stayed in
• Patients may be on medications indefinitely
• Evidence that antidepressants lose their
effectiveness with increased exposure to ADMs
(Amsterdam et al. 2009; Leykin et al. 2007)
42
Another meta-analysis (Maslej et al. 2020)…
43
Summary: Antidepressant Medications
44
Treatments for Depression
Control Condition
versus
Psychological Treatment 1
Psychological Treatment 2
45
Common Brief Empirically-based
Psychological Treatments
• Specialized Treatments
• Cognitive Behavioral Analysis System of Psychotherapy for Chronic
Depression
• Mindfulness-based Cognitive Behavioral Therapy for Recurrent Depression
• Couple therapy for Depression
46
Development of Psychological Treatments of
Depression
IPT
• Therapeutic Focus
• Changing irrational thought patterns and related behaviors
• Connecting thoughts, feelings and behaviors
• Types of therapeutic activities
• Testing depressogenic beliefs empirically
• Homework assignments such as thought logs to increase awareness of
contingencies
Meeting new people with “No one will be Feel sad, anxious “I have some good
a physical illness interested in me because Avoid others qualities that some
of my illness.” people will appreciate. I
am more than just my
illness.”
48
Beck‘s Cognitive Model of Depression
https://www.google.at/search?q=beck%27s+cognitive+model&client=firefox-b-
ab&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj2lPL14v3SAhVEsxQKHVX6AwMQ_AUICCg
49
B&biw=1920&bih=914#imgrc=BiKsH23c4fonGM:
Behavioral Activation (Jacobson et al. 1991)
• An elaboration of a component of Cognitive Therapy
• Therapeutic Focus: Doing is what is most important for change
• Identifying behavioral chains related to depression
• Changing avoidant behaviors and increasing reinforcing behaviors
• Avoidance may make physical illness and pain worse
Avoidance
Positive Reinforcement
51
Developers
52
Evidence for Psychological Treatments based on
Meta-Analyses
(Butler et al., 2006; Cuijipers et al. 2010; Cuijipers et al. 2011; Cuijipers et al. 2008)
Effect 0,8
0,7
0,6
Medium
Effect 0,5
0,4
0,3
Small 0,2
Effect 0,1
0
CT v. Control BA v. Control IPT v. Control CT v IPT CT v BA
-0,1
-0,2
53
CBT versus IPT
Jakobsen et al. 2012; meta-analysis of 6 trials comparing CBT versus IPT
Found no significant difference in outcome for two treatments, although
tendency to favor CBT.
2
IPT Mean difference in BDI
0
Total scores
-2
CBT -4
-6
-8
-10
-12
54
Psychological Treatments
• In studies of Cognitive Therapy and Behavioral Activation, but not
Interpersonal Therapy, publication bias was found
(Cuijipers et al. 2010 British J Psychiatry; Cuijipers et al. 2011; American J Psychiatry)
0,8
0,7
Medium 0,6
Effect 0,5
Effect size
0,4
Effect 0,1
0
Cognitive Therapy Behavioral Interpersonal
Activation Therapy
55
Treatments for Depression
versus
or in combination
with
Psychological Treatment Antidepressant Medication
56
Comparison studies
Elkin et al. 1989 ADM CT IPT Placebo
57
Comparison studies: Results
Elkin et al. 1989 ADM CT IPT Placebo
58
Combined Studies
60
Bidirectional cortico-limbic interaction in depression
62
Depression among Cancer Patients (will discuss
more about cancer later in the course)
• Depression treatments need to be tested in patient groups with
specific health issues.
• Depression is common among cancer patients, for example
• Evidence that group-based cognitive behavioral interventions for
breast cancer survivors can reduce depressive symptoms compared
to control group over 1 year follow-up period.
• Randomized controlled trial of 10 week group intervention compared
to 1 day psychoeducational training.
• Followed over 5 years
• N = 240
• Found significant differences in depressive symptoms at 5 year follow-up,
supporting evidence that the intervention is effective.
Stagl, Jamie M.,Antoni, Michael H.,Lechner, Suzanne C.,Bouchard, Laura C.,Blomberg, Bonnie B.,Glück,
Stefan,Derhagopian, Robert P.,Carver, Charles S. Health Psychology, Vol 34(2), Feb 2015, 176-180
63
Why Consider CBT for the Treatment of
Major Depression?
• Acceptable
• Recent meta-analysis indicates that psychotherapy is preferred
3:1 to pharmacotherapy for depression (McHugh et al., 2013, J
Clin Psychiatry)
• Efficacious and Cost-Effective
• CBT is more cost-effective than pharmacotherapy over follow-
up periods) (Dobson et al. 2009)
• Long-term Maintenance of Gains
• CBT has enduring effect over time (Cuijpers et al., 2013, BMJ
open)
Cognitive Behavioral Analysis System of
Psychotherapy (CBASP) for chronic depression
(McCullough et al., 2000)
65
CBASP v ADM Studies
68
Mindfulness-based cognitive therapy for
relapse prevention (Segal, Williams, & Teasdale, 2002)
• Will come back to this type of therapy when discuss chronic pain
69
Couple Therapy for Depression?
• There is a .4 correlation between relationship distress and
depression (Hahlweg, 2003; Whisman, 2001).
• 50% of suicide attempts are preceded by relationship conflicts
• Relationship distress is a moderator for treatment outcome in
depression (Denton et al., 2010)
• Relationship conflict predicts relapse
(Hooley & Teasdale, 1989)
70
Couple Therapy
71
Guidelines
Severity England U.S. Germany
Of Depression (NICE, 2009; updated (APA 2010) (DGPPN, 2012)
2018)
(physical activity
programs, too)
72
Effectiveness Research
• Conclusion:
• CBT is effective for depression in practice, but less effective than is
found in RCTs.
• Generalizability from RCTs is a problem
• e.g., as much as 76% of patients in clinical practice would be excluded from
RCTs
73
Dissemination Issues
• Less than 25% get treatment world-wide
• Even in high income countries, major public health gaps (e.g. 21% in
U.S. get “minimally” recommended treatment)
• Issues
• Costs
• Stigma
• Availability and training
74
Dissemination Issues
• More than half in need of treatment are undetected in primary
care.
75
Public Health Implications
76
Next Steps
77
What works?
78
Other treatments
79
Psychodynamic Therapies
80
Assigned readings
81