An everyday sequence: Feeling bad?

• How bad is it?We’ll call the doctor

So what happens next?

Depression Toward a working protocol

David P. Armentrout, Ph.D., C.T.S.

Depression?

Everyone has a bad day, so what’s the big deal?

What do these people have in

common?

Inventor of FMInventor of EEG

Renowned Child Psychologist

AcademicScientists

…and these people?

US Secretary ofDefense

White House Counsel

Ex-PresidentSouth Korea

Wife of GermanChancellor

Roman General

Politics,Leaders

…and ?

Acclaimedmusician

PopularActress

Popular SyndicatedAuthor

Nobel author

Man ofSteel

Actor, SNL

CreativeArtists

“For godly grief and the pain God is permitted to direct, produce a repentance that leads and contributes to salvation and deliverance from evil, and it never brings

regret; but worldly grief, the hopeless sorrow that is characteristic of the pagan world, is deadly – breeding and ending in

death.”

II Corinthians 7: 10

…, it killsKurt Cobain 1994Shotgun

Marilyn Monroe 1962Sleeping pill overdose

James ForrestalJumped 16th fl window

Vince Foster 1993gunshot

Amy Vanderbilt 1974Jumped from apt.

Hemingway 1969Sleeping pill overdose

Roh Moo-hyun 2009Jumped, 100 ft cliff

Steeve Reeves 1959 Luger shot to head

Hannelore Kohl 2001Sleeping pill overdose

Edwin Armstrong Jumped 13 floor

Marc Antony 30 BCFell on own sword

Hans Berger 1991hanging

B Bettelheim 1990Self suffocation

John Belushi Barbiturate overdose

Depression also has a morbidity…

• 18.8 mil. Americans a year (9.5%)• 100 million worldwide at any given time • Life time prevalence – 15.3% - 17.9% M.D.D.,

35.4% any depression• Leading cause of disability in US & market

economies• Suicide = 7th leading cause of death, 3rd in 15-

24 year olds

Disease Burden (Adjusted Life Years)• M.D.D. 2nd only to ischemic

heart disease in magnitude of disease burden

• Costs over 44 billion dollars per year in US

• By 2020 WHO projects unipolar depression to be second only to ischemic heart disease in disease burden, and the leading disease burden for women and in developing countries.

– 1982 Hagnell, et al: Sweden, 1/10 mid 60s, 1/6 in mid 70s. Ten fold increase in young men (20s & 30s)

– 1989 Klerman & Weissman: Incidence and prevalence of depression increasing and age of onset decreasing for successive birth cohorts. Increase for all ages from 1960 to 1975.

– 1992 Cross-National Collaborative Group: reported overall increase in rates of depression over time.

– 1993 Lewinsohn, et. al: Confirmed the increasing rates in younger cohorts in 1,710 Ss. Robust controls for

current mood, social desirability response bias, labeling, & time since episode did not reduce the Age Cohort Effect.

An Increasing/Pandemic Problem

Increasing rates cont.

– 1994, Wittchen, et. al: Successively more recently born cohorts have greater depression & more depressive sx; positive affect stable over time, depressive affect decreases over the adult life span.

– 1996 Prosser & McArdle: Major depression and the incidence of suicide increasing in US and UK in adolescents, particularly among males.

– 1999 Sandanger, et. al.: Incidence rates for depression increased significantly in Norway from 1930 and 1991.

All this in the face of increased resources:

• From 1988 to 1999 # psychiatrists increased to 39k, 1.3k/yr = 43% increase from 1988 to 2007.

• Ratio in 1998 md to non-md, @ 1:3 : addiction counselors, forensic counselors, grief counselors, marriage counselors, pastoral counselors, lay ministries, rehab counselors, social workers, developmental psychologists, neuropsychologists, geropsychologists, school counselors, psychiatric nurses, psychologists (clinical, school, counseling, etc), etc. etc. etc.

• California 2007: 1 counselor for every 815.3 students, 1 psychologist for every 1,363.6, 1 social worker for every 18,118 and 1 librarian for every 5,123.8 students.

And Then There’s Medication• 1950s-1988 tricyclics, MAO inhibitors• 1988 Fluoxetine (Prozac) released by

FDA• 103% increase in prescriptions in U.S.

(13.3 to 27million) from 1996 to 2005.

2012: 125 branded SSRIs, SNRIs, TCA, TeCAs:

• Celexa, Cipramil, Cipram, Dalsan, Recital, Emocal, Sepram, Seropram, Citox, Cital, Priligy, Lexapro, Cipralex, Seroplex, Esertia, Prozac, Fontex, Seromex, Seronil, Sarafem, Ladose, Motivest, Flutop, Fluctin (EUR), Fluox (NZ), Depress (UZB), Lovan (AUS), Prodep (IND), Luvox, Fevarin, Faverin, Dumyrox, Favoxil, Movox, Upstene, Paxil, Seroxat, Sereupin, Aropax, Deroxat, Divarius, Rexetin, Xetanor, Paroxat, Loxamine, Deparoc, Zoloft, Lustral, Serlain, Asentra, Viibryd, Zelmid, Normud, Effexor, Pristiq, Cymbalta, Yentreve, Dalcipran, Ixel, Savella, Levomilnacipran, Meridia, Reductil,Bicifadine, SEP-227162, Edivoxetine, Elavil, Tryptizol, Laroxyl, Amioxid, Ambivalon, Equilibrin, Evadyne, Anafranil, Deparon, Tinoran, Norpramin, Pertofrane, Noveril, Victoril, Istonil, Istonyl, Miroistonil, Prothiaden, Adapin, Sinequan, Tofranil, Janimine, Praminil, Imiprex, Elepsin, Lomont, Gamanil, Deanxit, Dixeran, Melixeran, Trausabun, Timaxel, Pamelor, Aventyl, Norpress, Agedal, Elronon, Nogedal, Azafen/Azaphen, Depressin, Vagran, Vivactil, Kevopril, Kinupril, Adeprim, Quinuprine, Asendin. Deprilept, Ludiomil, Psymion, Mazanor, Sanorex, Bolvidon, Norval, Tolvon, Remeron, Avanza, Zispin, Tecipul

The Banished Child:

• Nemifitide–80% effective, no side effect vs. 40%

for the SSRIs–10 IM injections in 6w, then 1 per

year–UK, FDA approved, then blocked by

gov & big pharma

Not the expected/desired panacea:• Medication Problems:

– Side effect, discontinuance, improper dosage– BMJ 2005, adults taking SSRIs have higher than

expected rates of suicide– 2005 FDA launches a review of antidepressants &

adult suicidality– 2005, Moncrief & Kirsch – “very poor outcomes in

longitudinal follow-up studies for people treated for depression, both in hospital & community

– Kirsch & Moore, 2002 – 80% of response to antidepressant medication (SSRIs) duplicated in placebo control groups, and the mean difference between drug and placebo was 2 pts on the HAM-D

Basics for Understanding Depression:Taxonic (42) or Dimensional

• Neurotic Post Partum Pure Depressive Diseas • Psychotic Melancholic Schizophrenic • Reactive Vital Atypical • Endogenous Symptomatic Seasonal Affective • Exogenous Periodic Physiological S Type • Involutional Somatic Depressive Spectrum Diseasee• Unipolar Simple Physiological J Type

• Cyclothymic Normal Adjstmnt. Dis with dep mood • Mourning Hostile Major Depressive Disorder • Masked Dysthymia Physiological Retardation\• Bipolar Primary Bereavement• Personal Secondary Schizo-Affective• Severe Biological Exhaustion Depression• • Mild One Dimension Secondary to prob. of living

If we don’t do

something different -

Our understanding of depression is a mess.

And, we have ignored the spiritual nature of our being…

• 1987. Fehring, Brennan & Keller. Spiritual well being is inversely associated with depression and negative mood.

• 1990. Brown, et al. Inverse relationship between religiosity and depression for both males and females with lower levels of depression seen in respondents with higher levels of religiosity.

• 1991. Genia & Shaw. Intrinsic religious commitment is associated with lower levels of depression.

A seminal spiritual study..

• 1991. Balk. Religion may play role in helping youth (14-19) face the death of a sibling. Religious youth had far more depressive symptoms than non-religious youth at the time following the death of their sibling. By the time of the interview av. = 24mos) religious youth had only mild symptoms while non-religious were still feeling depressed and confused.

NehemiahJesus

Designed by God

“For Godly grief and the pain God is permitted to direct, produce

a repentance that leads to salvation and deliverance from evil,

and it never brings regret; But worldly grief (the hopeless

sorrow that is characteristic of the pagan world) is deadly,

breeding and ending in death.” II Cor 7: 10

A Biblical Model of Depression

• Universality of depression• Both Taxonic and Dimensional• Process is important• Etiology is important

Two

Pathways(taxons):

God’s

Path &

The Deadly Spiral

Assessment: What should a dog do when he catches the car?

• Emotion-driven: Myth of the black hole• If there’s muck I’m stuck• I have to fix it right now

• Assessment-Driven: • Course of action determined by wisdom/discernment• The data can be made objective

A 4-Level Approach to Screening

1. Incidence (categorical)2. Severity (Dimensional)3. Etiology

- Psychosocial Spiritual Etiologies (Dimensional)- Biological Etiologies (Dimensional)

4. Process (Dimensional &Taxonic)

Level 1: Incidence

• The One Question Assessment (90% sensitive)• The Two Question Assessment (Arroll, et al.,

2003)• During the past month have you often been bothered

by feeling down, depressed or hopeless?• And, during the past month have you often been

bothered by little interest or pleasure in doing things?

Level 2: Subjective Severity

• SIGECAPS – Sleep: increase or decrease in sleep pattern– Interest: anhedonia – loss of normal interest– Guilt: feelings of guilt or worthlessness– Energy: low energy or fatigue– Concentration: difficulty focusing attention– Appetite: wt. increase or decrease, 5%/month– Psychomotor: agitation/restless or slowing– Suicide: life worth living? Active ideation?

(Criteria: MDD: 5+/2w/mood,Dysthymia: 2+/2y/MOOD?)

Level 2: Objective Severity• HDI (Hamilton Depression Inventory, CRS & BDI (Beck Depression

Inventory)– Most frequently used in research (Ham-D), r = .95. r = .93 with BDI.

HAM-D includes anxiety & somatic component, BDI severity, subjective distress- commercially available

• SDS (Zung Self-Rating Depression Scale)– Quick, 1 transformation to index, scoring easy, readily available from

Eli Lily Pharmaceutical– For severity estimates, tracks progress

• PHQ-9 (from PRIME-MD)– Quick, most easily scored, readily available from Pfizer Pharmaceutical– Severity estimate, tracks progress– Sensitivity for MDD,78%; specificity 85%

• CES-D (Cntr Epidem.Study-Depression)– Frequency may be measured

Separation from God

Exhaustion

Purposelessness

GuiltLoss

Level 3: EtiologyLack of Intimacy

Anger/Self-Indulgence

Self Worth

Busyness

Level 3 Biological Etiologies

• One resident’s patient’s reported that God had told her she was depressed secondary to a chemical brain imbalance.

• True biological etiology– Disease– Medications– Sleep loss

Level Four: Process, DimensionalScreening For The Spiral

– Least responsive to simple intervention

– Higher risk patients– >somatic sx = delayed

response to fluoxetine

• Elements– Overwhlemed

– Feeling Control– Worthlessness/Helpless-

ness/Hopelessness– Behavioral Involvement– Cognitive Distortion– Multiplying, interactive factors

A useful initial workup covers all

four levels:IncidenceSeverityEtiologyProcess

Depression Assessment Inventory

• Symptoms (Incidence & Severity)– DSM frequency & intensity, patterns (including familial)– Morbid thinking

• Etiology – Depressogenic illnesses and/or drugs– Distance from God, Anger, Guilt, Lack of Purpose,

Exhaustion, Loss, Overwhelmed, Busyness, Worth/value, Intimacy/connection, Self-indulgence

• Spiral (Process)– Emotion Dominance, Distortion Triad, Behavioral

Elements, Cognitive Distortions

Final Thoughts

• “Keep your heart with all vigilance and above all you guard, for out of it flow the springs of life.”

Proverbs 4: 23

Be Blessed !

Criteria

• Major Depression– 5 or more of the sx present

for two weeks– mood change or

anhedonia present– significant distress or

impaired function– not due to substance

abuse or med illness – not due to bereavement– no manic episode

• Dysthymia– Depressed mood most of

the day, most days x 2y– never w/o sx for more

than 2 months– not recurrent MD– no manic history– not due to substance

abuse or med illness– significant distress or

impaired function

Criteria

• Recurrent Major Depression– Multiple episodes

separated by periods of reduced sx

• Adjustment Disorder w/ Depressed Mood– onset w/in three months

or identifiable stressor– does not continue more

than 6 months– significant distress or

impaired function