Week 9/2 Depression III

Question 0

Cognitive and behavioural processes to target

Answer 0

Cognitive
 Depressogenic thinking

 Behavioral processes to target
 Low reinforcement and negative life event
 Skill deficits (social for ex.

Question 1

CBT Model of Depression
Underlying diathesis-stress model

Answer 1

Personal diatheses interact with stressful life events to disrupt
normal mood
 Depression maintained by negative cognitive and behavioral processes

Question 2

Emotional Spirals (linked to depression)

Answer 2

Depression may begin, or deepen, as part of a DOWNWARD EMOTIONAL SPIRAL

Negative events may breed negative moods… negative moods, negative behaviors … and negative behaviors, may produce negative thoughts and expectations for the future

Remember, works both ways, downward and upward.

Positive triggers can start a chain of pleasant feelings, events, and thoughts.

Therapists, work a an experiment.

Question 3

Cognitive Techniques in CBT
 Goal is to?

Answer 3

help youths LEARN how to:
 Observe their thoughts, feelings, and behavior
 Consider alternative explanation
 Solve problems and make rational decisions

 Therapy as observation and experiment
Assess the accuracy and affective consequences of their
thinking
 Try correcting your thought and see what happens (like experiement, collect data)

 Match developmental level
Use of concrete examples and cartoons

Garfield example comic. Event, gbeliefs, cognitive, alternatives. Bad parent/being, really isolated incident.

Question 4

Saw examle of homework and keep data of

Answer 4

Mood?

Reason grade on test. Alternatives and actions!

Question 5

Negative thoughts are risky!

Answer 5

Rumination if no alternatives found so start with behavioural techniques.

Question 6

Behavioral Techniques in CBT

Answer 6

 Keep track of mood and activity
How do you feel?
What are you doing?

 Develop list of rewarding activities
Activities that produce pride
Activities that produce pleasure

Question 7

Are these good rewarding activities? not?
Taking a long walk
Talking on the phone
Being on a baseball or softball team Volunteering at the local soup kitchen
Why or why not

Answer 7

Walkin (location,mle try of time and ruminating need to weigh)
Talking,
Softball team
Volunteering soup kitchen

Remember very small things are often enough. Food book, TV.

Question 8

Change habits, cbt and depression

Answer 8

 Address environmental obstacles
 Address skill deficits,
 Monitor IMPACT and refine plan obviously follow up.

Question 9

Need tangible data to prove to ppl

Answer 9

Cbt is working.

Question 10

Antidepressant Medication, to treat depression.

Answer 10

 Developmental differences
Many effective medications for adults
 Some do not work at all in children
 Most do not work as well in adolescents
 May be due to differences in brain development or metabolism, but are unsure

So not a 1:1 cordon dance between kids and adults

Question 11

Tricyclic antidepressants, for depression

Answer 11

 Prevent the reuptake of norepinephrine and serotonin in the synapses or by increasing the
responsiveness of receptors to these neurotransmitters
 No evidence of efficacy in youth

Question 12

Monoamine oxidase inhibitors (MAOIs) for depression

Answer 12

 MAO is an enzyme that breaks down some neurotransmitters
 MAO inhibitors stop this enzyme thus increasing the level of neurotransmitters in the synapse
 Some mixed evidence of efficacy in teens
 Potentially lethal side effects
 Interacts with foods rich in a particular amino acid (tyramine) and can lead to a potentail fatal increase in blood pressure
 Red wine, beer, chocolate, aged/ripened cheese

Question 13

Selective serotonin reuptake inhibitors (SSRIs) for depression

Answer 13

 Inhibit the reuptake of serotonin so that more is available in the synapse
 Similar to tricyclics, but more specifially focused on serotonin
 Good evidence for fluoxetine (Prozac) in teens
 Tend not to be fatal in overdose
 Side effects: agitation, jitteriness, anger, hostility, nausea, stomach cramps

Question 14

Antidepressants for Children and Adolescents contd

Answer 14

 SSRIs show some evidence of efficacy
 Suggestion of increased risk of suicide!

 Black-box warning by the FDA
 Appears on the package insert for medication
 Warns of serious adverse side effects
 Most serious warning the FDA gives
 Named for the black border around the warning

Question 15

Black-Box Warning history for ssri (like Prozac)

Answer 15

 Began with concern about one particular type of drug (Paxil)
 FDA requested data from all RCTs involving antidepressants
 Nine different drugs, 25 trials
 Independent team of experts conducted analyses
 Found higher levels of suicidal thoughts and behavior in patients treated with antidepressants compared to placebos
 No deaths from suicides were observed in these trials (+4000 patients)!
 Similar findings in a follow-up study with more patients

But….
 Studies not involving RCTs have shown that use of antidepressants is associated with decreased suicidality
 Epidemiological data indicates that as use of antidepressants goes up, suicidality goes down
 Note that adolescent suicide rates in the US increased for the first time in 2004, after many years of decrease
 Speculation that this was, in part, due to adolescents not being treated for depression, scared by warning.

Question 16

Most Recent Study
 Gibbons et al. 2012
 Obtained complete longitudinal data from RCTs for Prozac (fluoxetine) from the drug companies and the Treatment for Adolescents with Depression (TADS) study
 Built on previous studies by including additional data
 Examined association between treatment group and clinician ratings of suicidal ideation as well as adverse event reports

Answer 16

Did not find higher rates of suicidal ideation in youth treated with Prozac compared to placebo

Decrease of antidepressant use shows increase in suicide. Due to black box warning. No difference in actual suicides, not enough power perhaps. Only looked at poisoning method.
Also looked at adults, not included in black box warning, still saw decrease. No chance either.

Question 17

Antidepressant Use in Children and Adults
where are w know in. The debate?

Answer 17

 Evidence on whether the SSRIs increase suicidal ideation in children is characterized as mixed
 Balancing risk and benefit
 Possible increase of suicical ideation
 Risk of suicidal ideation of depression is left untreated
 Some evidence that some SSRIs (e.g., Prozac) may confer acceptable benefit:risk ratio for adolescents

Question 18

Treatment for Adolescents with Depression Study (TADS), like that adhd MTA one.

Answer 18

CBT
 Evidence for CBT in treating youth depression
 10 RCTs suggested CBT was efficacious
 40% of patients did not respond
 Significant relapse rates for those who do improve
 Room to improve treatment

 Medication
 One RCT suggesting Prozac was efficacious
 SSRIs were increasingly being used, making it important to examine it’s effectiveness in a sample of depressed adolescents

 Combination
 Clinicians often recommended combined SSRI and CBT
 Not clear how they compare to each other, or if the combination is more beneficial then either alone

Question 19

TADS Goals

Answer 19

 Using a sample of patients representative of those ofound in clinical practice:
 (1) What is the effectiveness of pharmacological treatment for depression in adolescents?
 (2) What is the effectiveness of CBT for the treatment of adolescent depression?
 (3) How do these treatments compare?

Question 20

TADS
Participants – 13 sites
– 439 youths enrolled
– age 12 to 17
– 54% female
– MDD, moderate to severe
 Design
– Random assignment
– CBT, SSRI, CBT+SSRI, pill placebo
– Treated for 12 weeks

Answer 20

Active medication, by self or in combination.
Showed improvement, compared to no meds. By self and Therapisr.

So on average meds helps.

Combination group aside.
Cbt might be helpful for suicidality
Reccomened combo for moderate to severe depression.

Overall, groups with active medication did better in terms of depression symptoms. Rocked world of therpay, not cbt. Why?

Question 21

Not a lot of support for CBT, only in combination for Suicidality.
 CBT did not outperform a pill placebo
 Contrasts with previous evidence
 Why? (3 reasons)

Answer 21

Sample characteristics
 Some evidence that CBT may not work as well in a more severe
sample
 TADS sample was very severe

Treatment manual
 Very flexible
 Therapists given a lot of latitude in picking from different “modules”
 May have resulted in participants getting fewer CBT techniques

TADS Follow Up
 Initial TADS results for 12 weeks of treatment
 Actually conducted 36 weeks of treatment
 After 12 weeks, SSRI and placebo groups unblinded ethical reasons
 Placebo non-responders got treatment
 Placebo responders were monitored

Over time no difference! Cbt just takes longer. But lacks control of untreated. Cbt could be natural remission line.

It is possible that the severity of sample may have meant that CBT alone took longer to work
 Suicidal ideation is significantly more common in those treated with medication alone, compared to both CBT and combined treatment

Question 22

TADS Follow Up

Answer 22

 Initial TADS results for 12 weeks of treatment
 Actually conducted 36 weeks of treatment
 After 12 weeks, SSRI and placebo groups unblinded ethical reasons
 Placebo non-responders got treatment
 Placebo responders were monitored

Over time no difference! Cbt just takes longer. But lacks control of untreated. Cbt could be natural remission line.

It is possible that the severity of sample may have meant that CBT alone took longer to work
 Suicidal ideation is significantly more common in those treated with medication alone, compared to both CBT and combined treatment

Question 23

No treatment control , a limitation

Answer 23

Artuable.
Unethical,
And remission rate is not this fast, as it was for those having cbt! So faster than nature.

Question 24

Summary of tads.

Answer 24

 CBT for child and adolescent depression can be effective
 May not be the best choice for severe cases
 Evidence for the effectiveness of SSRIs
 Have to weigh the risks and the benefits
 TADS authors concluded that CBT in combination with SSRIs may prove protective against suicidality

Question 25

Treatment for Depression in Preschoolers
 Diagnosis of depression in preschoolers is very new
 Not much is known about effective treatments
 As of 2006, no studies had examining the safety and efficacy of prescribing medication for preschool mood disorders
 Also no psychotherapy trials
 Note that prescribing occurs “off-label”
 3-9/1000 U.S. preschoolers treated with psychotropic meds in the 1990s
 Most common prescriptions are for stimulants, adhd meds

Answer 25

Treatment for Depression in Preschoolers
 Luby and colleagues have developed a version of parent-management training that focuses on helping parents learn to manage their children’s moods

 Therapy is recommended as the first approach
 If symptoms are severe and persist, fluoxetine (Prozac) has the best risk/benefit profile in older children and is recommended as the first choice in preschoolers