HD 3700 1st Edition Lecture 13 Outline of Last Lecture I Brain Imaging II Ophelia s Dilemma III How the brain is organized IV Neurons V Neurotransmission Outline of Current Lecture I Polonius the psychiatrist II Defining depression III Beck s Cognitive Theory IV The brain and depression V Neurons and depression VI MAO inhibitors tricyclics SSRIs and how they work on serotonergic and noradrenergic pathways Current Lecture I Act II Scene II Polonius the Psychiatrist Polonius is the fool of the play and doesn t know it Gertude is not intelligent either Claudius is the best reader of the play Polonius is the bad psychiatrist says I know what s wrong with that person but he has no idea biggest mistake made by clinicians is jumping to conclusions II Defining depression There is a debate about the whole idea of diagnosis labels follow someone o Must take your time with diagnosis especially with children o Diagnosis necessary to frame their problem and treat them don t want to underpathologize patients Range of mood o Severe mania o Hypomania mild to moderate mania o Normal balanced mood o Mild to moderate depression o Severe depression Range of mood much more variable in young people Kinds of depression o Dysthymia mild depression Never so depressed that they can t function Down a lot of the time Persistent Depressive Disorder Depressed mood for most of the day for more days than not Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self esteem Poor concentration Feelings of hopelessness Present for 2 years o Unipolar depression depression only Recurrent experiences of severe depressive episodes Major Depressive Disorder Depressed mood most of the day nearly every day Diminished interest or pleasure in all activities Significant weight loss or weight gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy nearly every day Feelings of worthlessness Diminished ability to think or concentrate Recurrent thoughts of death suicidal ideation o Bipolar Depression I depression mania Manic depression cycle with periods of severe depression with periods of psychotic mania o Bipolar Depression II depression hypomania If you have relative with Bipolar I you might have something that seems like Bipolar I but less serious More common than Bipolar I Hypomanic episodes followed by severe depressive episodes o Cyclothymia dysthymia hypomania Periods of dysthymia and hypomania Dysthymia o Depressed mood for most of the day Prevalence o 5 11 lifetime prevalence o 10 15 million people a year o 50 recurrence after a single episode o Rule of 7s 1 7 with recurrent depressive illness commits suicide 70 of suicides have depressive illness 70 of suicides see their primary physician within 6 weeks of suicide th Suicide is the 7 leading cause of death Ways to explain depression o Anger turned toward the self Freud psychoanalysts o Defense Sadness blocks Anger and Guilt o Attributional Style Global Permanent Internal Depressive attributions I m bad all around this will never be different and I m inadequate o Problems with Attachment depression mourning See this in kids with foster care o Biological Disorder Some evidence for this with major depressive disorder and bipolar disorder III Beck s Cognitive Model Beck s Cognitive model of the emotions o Event thought interpretation emotion o Interpret the event differently o Micro thought that interprets the event and triggers the feelings o Psychotherapy is about changing the interpretation Fixing the distorted interpretations Attributional style and depression why we think things happen o Non depressed external single event specific domain o Depressed internal permanent global o Cognitive treatment of depression is getting the patients to become aware of these interpretations and change the outcomes Freud changing the association IV The brain and depression Classical model of inherited disease o 100 will develop the inherited disease o But if we think of depression as a disease why is it that identical twins don t always both get depression The Multi Hit Model o Biological risk factors Enzyme production Brain development in utero Brain development in adolescence o Environmental risk factors Early trauma Physical abuse Lost a parent Witnessed violence o Life events and how you are taught to cope Interact with genetic vulnerability factors Three kinds of people o Those who don t suffer from depression or dysthymia who have bad days will grieve a loss but don t spiral down into a major depressive episode o Those who usually don t suffer from depression but when stressed beyond a certain point develop depressive symptoms and benefit from a short term use of medication and therapy to come out of it When the stress or crisis resolves they often taper off their meds without a relapse o Those who are chronically depressed without medication Psychotherapy may be helpful in that it provides insight and ways to minimize stress but these people only experience substantial relief with medication 5 of people What can the brain tell us about depression o Structure o Pathways o Neuron action Brain structure Depression Stress and the HPA Axis o When you feel threatened the hypothalamus sends out cortico tropinreleasing hormone CRH which releases adrenocorticotropin hormone ACTH from the pituitary gland ACTH surges through the body releasing stress reducing hormones such as cortisol from the adrenal gland Once cortisol reaches a certain level the hypothalamus shuts off the CRH o But in depressed people this shutdown fails possibly because the perceived stress is chronic leading to excess amounts of CRH This also leads to dentrite damage in the hippocampus neurons that have CRH receptors Damaged hippocampal dendrites are linked to depression and prolonged grief o Evidence for this in rats with constant stress exposure exhibit depression and damage in hippocampal neurons o Being chronically depressed is keeping the body agitated and damaging part of the brain Brain Structure depression s neuroanatomical circuitry o Study this diagram for the prelim Figure 8 1 o Prefrontal Cortex decreased volume and increased activity linked to depression o Hippocampus also seems smaller in chronically depressed patients o But the amygdala really part of the hippocampus is larger perhaps because it processes emotional experience o Anterior Cingulate Cortex It is activated by extreme sadness o Nucleus Accumbens linked to adaptability and