E T IOL O GY OF DE PR E SSION: BRAIN ACTIVITY

• Depressed patients have higher

overall brain metabolic activity
but low activity in left PFC
• Interrupted or deteriorated
connections in the networks
devoted to mood regulation
• Brain activity differences:
• Amygdala (high in MDD)
• Hippocampus and dorsolateral PFC (low in
MDD)
• Striatum (low in MDD, high in BPD)
ETIOLOGY OF DEPRESSION

• Psychological Factors
• Psychoanalytic theory
• Anger turned inward
• Self-criticism, self-reproach,
guilt, sensitivity, self-pity
• Pessimistic thinking styles
• Learned helplessness
• Beck’s cognitive triad
• Self, world, future
• Depressogenic schemas
• Attribution theory
• Ruminating style
 ETIOLOGY OF DEPRESSION

• Psychosocial Context of Depression:

• Problem-solving skills
• Self-management skills
• Social skills
• Economic deprivation
• Marital/relationship conflict
• History of abuse
• Psychosocial Factors
• Poor interpersonal skills
• Nonverbal behavior
• Reassurance seeking
• Sparse social networks
• Neuroticism (negative affectivity)
 ETIOLOGY OF DEPRESSION

• ACES, stressful life events • Kindling Effect—residual

• Studies on ELS (e.g. LeMoult et al., neurological traces that
2020) increase vulnerability to further
occurrence
• 5 domains assoc with MDD: sexual
abuse, physical abuse,
emotional abuse, death of a
family member, domestic
violence
• 3 domains NOT assoc with
MDD: poverty, physical
illness/injury, natural disaster
MANAGEMENT AND TREATMENT:
DEPRESSIVE DISORDERS
SUICIDE & NON-SUICIDAL SELF-
INJURY

Class 5
Kelli McCormick, PsyD
 MANAGEMENT & TREATMENT OF DEPRESSION

• Interrupting the Depression

Cycle
• Depression = whole-body
illness!
• Using the BDI (or sx rating
scale) to track sx
• Medications/Drug Therapies
• All are equally effective—65-85%
show signif improvement
• NOT addictive
• Only 1 in 3 will achieve remission
with first antidepressant
• Rx should be continued for at least
12 months after recovery to
prevent relapse
ANTIDEPRESSANT
MEDICATIONS
• First antidepressant = ISONIAZID
(1952)
• Tricyclics—enhance effects of NE and
5HT
• Side effects: orthostatic hypotension,
drowsiness, weight gain,
anticholinergic effects (constipation,
dry mouth, urinary retention, rapid
heartbeat)
• Overdose is life-threatening
• Elavil (amitriptyline), Tofranil
(imipramine), Aventyl/Pamelor
(nortriptyline), Norpramin
(desipramine), Sinequan (doxepin)
 ANTIDEPRESSANT
MEDICATIONS

• MAO Inhibitors
• Monoamine oxidase = enzyme
that breaks down NE
• Side effects: agitation, panic
attacks, insomnia, frequent
interactions with other drugs,
interactions with foods
containing tyramine
• Marplan (isocarboxazid), Parnate
(tranylcypromine), Nardil
(phenelzine)
HOW MAOIS WORK…
ANTIDEPRESSANT
MEDICATIONS

• SSRI’s
• Block reuptake of 5HT
• No overdose danger
• Side effects: GI irritation, headache,
insomnia, dizziness, tremor,
nervousness, sexual dysfunction
• Prozac (fluoxetine), Paxil (paroxetine),
Zoloft (sertraline), Luvox
(fluvoxamine), Celexa (citalopram),
Lexapro (escitalopram), Viibryd
(vilazadone)
• Symbyax (OFC) = fluoxetine +
olanzepine
HOW SSRIS WORK…
 ANTIDEPRESSANT
MEDICATIONS

• “New generation” antidepressants

• Most effects on NE
• Desyrel (trazodone), Wellbutrin (bupropion)
• SNRI’s
• Most effective for pain, somatization,
autoimmune, and menopause
• Strong discontinuation syndrome
• Effexor (venlafaxine), Cymbalta
(duloxetine), Pristiq (desvenlafaxine)
• On the horizon…
• Ketamine, psilocybin, TMS, vagal nerve
stim, DBS, Brexanolone
EFFICACY OF MEDICATIONS FOR MDD
 PSYCHOTHERAPIES FOR
DEPRESSION

• Must break the stress

response cycle!
• CBT
• Behavioral Activation
• How to decrease Rumination:
• Mindfulness, positive
distraction
• Problem-solving, lowering
expectations, acceptance
• Avoiding future traps
PSYCHOTHERAPIES FOR
DEPRESSION

• Interpersonal Psychotherapy (IPT)

• Recent losses, role disputes, social
transitions, social skills
• Alternative therapies
• Light therapy, nutrition (anti-
inflammatory), exercise, self-help,
Group tx, ECT, sleep deprivation
• Importance of a Relapse
Prevention Plan
• Avoid: alcohol/drugs, negative
situations, judgmental or
demanding people, isolation,
brooding/rumination
 HELPFUL VIDEOS

• Screening for depression:

• https://video-alexanderstreet-com.libproxy.scu.edu/watch/depression-
assessment-2?context=channel:counseling-and-therapy-in-video
• Bipolar disorder, current MDE:
• https://video-alexanderstreet-com.libproxy.scu.edu/watch/depression-
assessment-4?context=channel:counseling-and-therapy-in-video
 T R E AT M E N T I S S U E S I N
CHILDREN AND ADOLESCENTS

• Medication-
• Efficacy of antidepressants
lower than in adults
• Psychotherapy should:
• Counteract loneliness and poor
self-esteem
• Foster social support and how to
obtain it
• Encourage feelings of self- “Failures and rejections may be
confidence and competence unavoidable, but it is the challenging
task of the therapist to put such crises
• Teach emotional regulation skills! in perspective and to limit their effect
• Positive: cognitive reappraisal, from being generalized into a sense of
problem-solving, acceptance total worth…” (Bemporad, 1991)

• Negative: avoidance,
suppression, rumination
 USEFUL INTERVENTIONS FOR
CHILDREN IN
PSYCHOTHERAPY

• Pleasant activity scheduling

• Identifying and challenging
cognitive distortions
• Reattribution training
• Problem-solving techniques
• Self-monitoring techniques
• Self-instructional techniques
• From Huberty (2009)
“The fact that adolescents have the ability to
critically assess themselves, while at the
same time lacking the life experiences needed
to moderate this ability, accounts for their
often extreme reactions to seemingly trivial
events…So despite obvious cognitive
development, the realization that we all
survive and grow regardless of immediate
adversity has not yet come into play in the
life of an adolescent…” (Bemporad, 1991)
 PARENT TRAINING

• Some effectiveness for Behavioral Parent Training (2017)

• Children ages 7-13
• Indiv CBT vs. BPT
• Both equally effective!

TADS study: Treatment for

Adolescents with Depression
(2007)
 SUICIDE AND SELF-INJURY

• 20-30 million experience period of

suicidal ideation in any given year
• Every 20 minutes in U.S.
• 93-97% = MDD, PTSD, psychosis
• Major mental disorder + self-
medication = extremely high risk
• Inherited vulnerabilty: serotonin
dysfunction
• Risk is higher for family members who
have lost a close relative to suicide
 SUICIDE

• Females to males: 3 to 1 attempts

• Males to females: 4-5 to 1
completions
• 2nd leading cause of death among
adols/young adults
• Watch for secondary gain in therapy
• Higher risk: white male youth, Native
American youth, white males over
50, LGBT youth, rape survivors,
chronic physical illness (e.g. AIDS or
MS)
• Suicide rates in military much higher
than general population
• Alcohol and drugs involved in 70-
75% of all suicide attempts
S U I C I D E R AT E S
ANNUAL DEATHS DUE TO SUICIDE
BY AGE AND GENDER
 MYTHS OF SUICIDE

• People who talk about suicide are unlikely to

commit suicide.
• Suicide occurs precipitously.
• Suicidal individuals are fully committed to their
death.
• Suicide is a problem of lifelong duration.
• Improvement after a crisis indicates that the risk
factor is over.
• The rich or the poor are more likely to attempt
suicide.
YOUTH SUICIDE

• Risk: feeling unwanted,

sexual assault, low family
fx, peer suicide
• Major negative life events
• Reasons for committing
suicide: relief, escape, make
people understand, revenge,
manipulation, to show how much
you love someone, to see if
someone loves you
 YOUTH SUICIDE

• Suicide risk: 7-8% of MDD

dx adols
• 19% of young people
contemplate or attempt
suicide each year

CDC Youth Risky Behavior

Survey (2017):
-Among high school students…
- Boys: 12% suicidal
ideation, 5.1% attempt
- Girls: 22% suicidal ideation,
9.3% attempt
SUICIDE ASSESSMENT
 SUICIDE RISK ASSESSMENT

• Direct Indicators: • Indirect Indicators:

• Suicide plan • Recent loss

• Lethality of method • Poor self-image

• Availability of means • Alcohol/drug use

• Isolation/withdrawal
• Prior attempt
• Negative receptiveness to help
• Response to prior attempt (tx?)
• Tunnel vision
• Increased anxiety
• Increased depression
• Poor daily functioning
• Increased hostility/anger
• Happiness or relief
IS PATH WARM?
 SUICIDE RISK ASSESSMENT

• Have you thought about hurting yourself?

• Do you want to die? Have you thought about wanting to die?
• Do you care if you life or die?
• Have you thought about suicide? Killing yourself?
• Do you feel like letting yourself die by ignoring your health? Not taking
medications? Doing something dangerous?
• If you have thought about these things, how long do the thoughts last?
• Do these thoughts happen every day?
• Can you think of anything that would keep you from hurting or killing yourself?
(e.g. religion, family, pets, finances)
• Can you think of any reasons why you should stay alive?
• Have you thought of a way to kill yourself?
• Does it scare you to think about going through with it?
• What are the chances of you carrying out an attempt?
• Have you noticed yourself talking about death or suicide more, even jokingly?
• Have you written/journaled about it? Have you thought about what you’d put in a
suicide note?
 SUICIDE RISK ASSESSMENT

• Have you thought about hurting yourself?

• Do you want to die? Have you thought about wanting to die?
• Do you care if you life or die?
• Have you thought about suicide? Killing yourself?
• Do you feel like letting yourself die by ignoring your health? Not taking medications? Doing
something dangerous?
• If you have thought about these things, how long do the thoughts last?
• Do these thoughts happen every day?
• Can you think of anything that would keep you from hurting or killing yourself? (e.g. religion,
family, pets, finances)
• Can you think of any reasons why you should stay alive?
• Have you thought of a way to kill yourself?
• Does it scare you to think about going through with it?
• What are the chances of you carrying out an attempt?
• Have you noticed yourself talking about death or suicide more, even jokingly?
• Have you written/journaled about it? Have you thought about what you’d put in a suicide note?
 •Do you have thoughts of wanting to hurt yourself? (how often, how
intense)
•Have you ever thought about killing yourself or wished you were
dead?
•What thoughts or plans do you have?
•Do you intend to carry out your plan?
•Do you have _____________ (means they identify)?
SUICIDE RISK •Are you thinking about harming yourself?
ASSESSMENT •Have you ever thought you would be better off dead?
QUESTIONS •Have you ever done anything to hurt yourself?
•How long have you been thinking about suicide?
•Do you want to die or do you want the pain to go away?
•What are the things that keep you from acting on your thoughts?
(reasons for living)
•What would increase the likelihood of you trying to hurt yourself?
•What is the intensity of the ideation now, vs the worst it has ever
been?
 R I S K FA C TO R S
•family history of suicide
•parental mental health
problems
•relationship problems with
parents
•LGBTQ
•homelessness
•history of abuse
•previous attempts
•depression
•other mental problems
•poor insight or judgment
•impulsivity
•medical illnesses
•barriers to accessing care or
therapeutic services
•incarceration
•school problems (failing, not
going, bullying)
•access to lethal means
•alcohol and drug use
•exposed to suicidal behavior
by others
•perceived lack of social
support and isolation
•hopelessness
•stressful life event/trigger
•male
•Native American/Alaskan
Native
 RED FLAGS

•thinking about or talking about suicide (suicidal ideation)

•plan for suicide
•increased risk-taking behavior (substance abuse, impulsive,
reckless)
•anxiety, depression, feeling hopeless or no sense of purpose
•social withdrawal and isolation
•irritability and anger
•mood change
•sense of being a burden
•suicide intent
 PROTECTIVE FACTORS

•cultural and •restricted access to lethal

religious/spiritual affiliation means
that discourage suicide •parents warm and supportive
•social support or contact with •active participation in therapy
a caring adult
•insight into symptoms and
•peer group at school triggers
•academic involvement •coping, problem solving, and
•parents involved in treatment conflict resolution skills
 THERAPY FOR SUICIDALITY

• Help clients: regulate

emotions, make them feel
valued and connected, and
instill hope
• Collaborative safety planning
• Support systems
• CBT
• DBT
SECTION III: SUICIDAL BEHAVIOR DISORDER

• A. suicide attempt within

last 24 mos
• B. R/O Nonsuicidal Self-
Injury
• C. Dx not applied to
suicidal ideation or
preparatory acts
• D. not initiated during
confusion/delirium
• E. R/O political or
religious objective
SECTION III: NON-SUICIDAL SELF-INJURY

• A. 5+ days intentional self-inflicted damage

to surface of body, expectation that injury
will lead to only minor/mod harm
• B. 1+ expectations:
• To relieve negative feeling or cognition
• To resolve interpersonal difficulty
• To induce positive feeling state
• C. Assoc with 1+:
• Precipitant
• Preoccupation
• Frequent thoughts
• D. Not socially sanctioned (tattoos,
piercing)
• E. Distress or impairment
• F. R/O psychosis, delirium or intoxication,
R/O neurodevelopmental disorder, R/O
other mental or medical
 NON-SUICIDAL SELF-INJURY

• Growing prevalence (12-37% adols,

12-20% young adults)
• Average age of onset: 12 y.o. (age 11-
15)
• More girls, more whites, more LGBT
• EMO and Goth kids = very high risk!
• Often goes undetected
• Check for infection risk
• Check for support
• Tx: DBT, prob-solving tx, solution-
focused tx
 NON-SUICIDAL SELF-INJURY

• Females to males: 3-4 to 1

• Treat the goal of behavior, not the
behavior
• Powerful correlation to drug use
during adol and young adulthood
• Dissociation
• “So what happens when you cut?”
• Causes:
• Emotional regulation deficits
• Dissociative experiences
• Body dysmorphic issues
• Anxiety/depression regulation
• Isolation and social cohesion needs
Elle, a 15-year-old female came to therapy at the
encouragement of her friends. Elle’s parents separated
2 months ago. Since then, Elle sleeps for the majority
of the day, reports decreased appetite, and little
enjoyment in activities. She hasn’t felt up to spending
time with friends, and she is not motivated to
continue to participate in soccer at school. Her grades
have also dropped. Elle denies drug and alcohol use.
She does not want her parents to know she came to
see you.
CASE EXAMPLE
At your next session, you assess for suicidality with
Elle. She endorses suicidal ideation but denies intent.
She also discusses how she has been self-harming
(cutting) the last few weeks. How do you proceed?
At your next session, you assess for suicidality with
Elle. She endorses suicidal ideation, has thought of a
specific plan, and cannot commit to keeping herself
safe. How do you proceed?