Transdiagnostic Depression Group Marco Sinai, Ph.D. Mood Disorders - - PowerPoint PPT Presentation
McGill University Health Centre Centre universitaire de sant McGill Transdiagnostic Depression Group Marco Sinai, Ph.D. Mood Disorders Program Outline Brief Introduction to BSD Brief Review of Psychosocial Interventions for BSD
Marco Sinai, Ph.D. Mood Disorders Program
McGill University Health Centre Centre universitaire de santé McGill
◼ Brief Introduction to BSD ◼ Brief Review of Psychosocial Interventions for BSD ◼ Description of BSD Group Therapy at the Allan ◼ Description of Results ◼ Discussion
◼
Biological illness that causes unusual shifts in:
◼ Mood, level of energy, and
ability to function
◼ Shift between periods of low
mood and lethargy (depression), and periods of high energy and/or irritability (manic)
◼
Manic pole: excessive positive emotions and associated features
◼ Mania (lasting >1 wk), Hypomania (lasting > 4 days) Cyclothymia
(personality trait)
◼
Depressive pole: major depressive episode lasting 2 weeks
◼ Identical dx criteria as unipolar depression ◼ Few clinical differences between unipolar and bipolar depressive episodes
◼
Mixed episode: Predominant symptoms from one polarity, but with features
from opposite polarity.
◼
Euthymic phase: Patient is asymptomatic but remains at risk of relapse.
◼
Comorbid disorders: Anxiety, Substance Use, Personality Disorders, ADHD
◼ Variable characteristics inherent in definition of mania:
◼
Hallucinations present in 4% to 40% of manic episodes (Rehm and Tyndall, 1993)
excessive positive emotions (happiness; euphoria) excessive negative emotions (anger; irritability)
inflated self- esteem pressured speech
(75% to 100%)
decreased need for sleep
(81%)
excessive involvement in pleasurable activities racing thoughts
(40 % to 100% )
distractibility increased activity/ agitation
(87%)
◼ Akiskal’s BSD Classification (not DSM)
◼ Bipolar I – Full-Blown Mania ◼ Bipolar I ½ - Depression with protracted Hypomania ◼ Bipolar II – Depression with Hypomania ◼ Bipolar II ½ - Cyclothymic Depressions (often
◼ Bipolar III – Antidepressant – Associated Hypomania ◼ Bipolar III ½ - Bipolairty masked – and unmasked –
◼ Bipolar IV – Hyperthymic Depression
◼ BSD Temperaments (Akiskal & Pinto, 1999)
◼ The Hypethymic temperament. Cheerful and overoptimistic;
warm, people-seeking, and extroverted; eloquent and jocular; overconfident and self-assured; high energy level, full of plans and improvident activities;
promiscuous; and habitual short sleeper.
◼ The Generalized Anxious temperament. Exaggerated
disposition toward worrying. Evolutionary advantage: “Survival of one’s kin”
◼ The Depressive Temperament. Sensitivity to suffering, a cardinal
feature of the depressive temperament, represents an important attribute in a species like ours, where caring for young and sick individuals is necessary for survival. Self-denying and devoted to others
◼ The Cyclothymic Temperament. Moody–temperamental
individuals, shifting from flamboyant to dysthymic, irritable, capricious, falling in and out of love easily. Evolutionary advantage: “pursuit of lovemaking opportunities”.
◼ Bio-Genetic risk
◼ Concordance studies point to high heritability of Bipolar I disorder
(Edvardsen et al., 2008)
◼ Many candidate genes exerting mild to moderate effects (Kerner, 2014)
Identical Twins 40% concordance Fraternal Twins 5% concordance
VS
◼ Genetic predisposition may underlie physiological abnormalities such
as Circadian Dysregulation and shifts in energy levels. ◼ Psychosocial risk
◼ Despite a strong genetic predisposition, psychosocial risk remains
substantial
◼ Need for psychosocial interventions as part of optimal treatment for
BSD
◼ Major Components
◼ Awareness of the disorder ◼ Treatment adherence ◼ Avoiding substance abuse ◼ Early detection of new episodes ◼ Regular habits and stress management
◼ Evidence
◼ Rigorously tested by Colom et al. (2003) ◼ 120 euthymic bipolar patients assigned to 21 sessions of group
psychoeducation or non-specific group meetings.
◼ At 2-year follow up, benefits of psychoeducation with regard to
percentage, number and time to recurrences, and hospitalization per patient. Efficacy maintained over 5 years, and effect sizes did not decrease.
◼ Major Components
◼ Psychoeducation about bipolar disorder ◼ Identification of triggers and dealing with long-term vulnerabilities ◼ Cognitive behavioral skills to cope with symptoms
◼ Evidence
◼ Improved outcomes compared to treatment as usual (Cochran et
al., 1984; Lam et al., 2005; Ball et al., 2006)
◼ No significant difference compared to individual or group
psychoeducation
◼ Zaretsky et al., 2008 - compared 7 sessions of individual psychoeducation to 20
weeks of individual CBT in 79 patients in full or partial remission. No differences in relapse rates over 12 months.
◼ Parikh et al., 2012 - a Canadian trial compared 6 session of group
psychoeducation to 20 weeks of individual CBT in 204 patients in full or partial
◼ Major Components
◼ Psychoeducation ◼ Communication enhancement training ◼ Problem solving skills training ◼ Support and self-care for caregivers
◼ Evidence
◼ Miklowitz 2003, 2008, 2013: bipolar I and II patients who received
pharmacotherapy and family focused therapy showed 30-35% lower rates of relapse at 2 years follow-up compared to treatment as usual.
◼ Components of DBT, ACT, MBCT
◼
Distress Tolerance tools
◼
Development of a different way (nonjudgmental) of relating to thoughts, feelings and bodily sensations
◼
Ability to switch attention away from negative thoughts and bodily sensations.
◼
Learn to ignore rather than challenge (classical CBT) negative thoughts and emotions
◼ Evidence
◼
Established effectiveness of third wave approaches in depression and anxiety disorders
◼
MCBT showed significantly reduced BDI and BAI scores compared to wait list control in Bipolar adults (Perich et al., 2008)
◼
DBT showed significantly better adherence to treatment, reduced suicidal ideation, and increased weeks being euthymic in adolescents (Goldstein et al., 2015)
◼
ACT showed significant improvement in anxiety, depressive and quality of life measures in uncontrolled study of 26 patients with BAD and comorbid
Melatonin signals “darkness” Cortisol signals “activation”
◼
During mania
◼
higher cortisol levels during the night compared to healthy controls
◼
earlier nadir for plasma cortisol compared to healthy controls
◼
Two hour phase advance when compared with healthy controls
◼
More daytime napping than when euthymic
◼
When euthymic
◼
lower melatonin and later melatonin peak during the night relative to healthy controls
◼
Approximate two hour phase advance of circadian motor activity
relative to healthy controls
(Salvatore et al., 2008
During mania Euthymic Control Control
◼ Sleep disturbance increases negative mood, irritability,
◼ At a neural level, affect and sleep circuits interact in bidirectional ways ◼ 35 hour sleep deprivation results in 60% greater amygdala activation to
negative stimuli relative to those who slept normally
◼ Deliberate sleep deprivation is a same-day powerful treatment for bipolar
(and unipolar) depression.
◼ 35 hour sleep deprivation triggers manic episodes in 5% of BSD patients ◼ Therapeutic sleep extension (“dark therapy”) has demonstrated that
stabilizing sleep reduced rapid cycling and decreases manic symptoms relative to treatment as usual group
◼ Lithium
◼ Slows down circadian periodicity and can modify circadian length – may
target circadian dysregulation
◼ In a study of seven rapid-cycling bipolar patients, five had a circadian
rhythm that ran fast, and lithium slowed the rhythm
Murray & Harvey, 2010
Adapted from: Ehlers et al. 1988
Life Events Change in Social Prompts (Social Zeitgebers = Unobservable Variables) Change in Stability of Social Rhythms Change in Stability of Biological Rhythms Change in Somatic Symptoms Manic and Depressive Episodes = Pathological Entrainment of Biological Rhythms
◼
Components
◼ Education about bipolar disorder ◼ Management of affective symptoms through adherence to medication
and stabilizing social rhythms
◼ Regulate daily routines ◼ Emphasizes the link between regular routines and moods ◼ Uses Social Rhythm Metric to monitor routines
◼ Resolution of interpersonal problems
◼ unresolved grief, social role transitions, interpersonal role disputes,
interpersonal deficits, grief for the lost healthy self
◼
Evidence:
◼ Frank et al. (2008) 175 patients with Bipolar I in acute phase.
◼ Weekly sessions until measures of depression and mania reached the lower
cutoff scores indicating remission for 4 weeks.
◼ Maintenance = biweekly for 12 weeks, monthly for two years.
◼ Compared to TAU:
◼ survived longer without a new affective episode. ◼ Improvements in occupational functioning.
◼ Enrolled 19 patients. 16 Treated to completion
◼ 75% of patients closer to depressive pole
◼ Integrative approach with elements of
◼ Psychoeducation ◼ IPSRT
◼ Interpersonal Therapy ◼ Social Rhythm Metric
◼ Third Wave CBT
◼ Mindfulness ◼ Distress Tolerance Skills ◼ Emotion Regulation Skills
◼ No group improvement in subjective sleep quality ◼ No evidence of improvement in interpersonal function ◼ No significant improvement in self-reported mood and
◼ Robust subjective improvement in cognitive function ◼ Self-reported improvements in productivity ◼ Self-reported improvement in self esteem
◼
Improved ability to function despite no improvement in mood and anxiety
◼
Emphasis on third wave approaches that:
◼ Targets behavioural avoidance ◼ Allows exploration and tolerance of
negative thoughts and mood
◼ Prioritizes life satisfaction vs
happiness
◼ Not enough patients referred to justify running
◼ Most patients (75%) referred to bipolar group
◼ Emphasis on Social Rhythms may not be
◼ Program was geared toward manic pole
◼ Unipolar depression episodes are more
◼ Most studies compare unipolar depression
◼ Studies that compare unipolar and bipolar
◼ Well designed studies show inconsistent or no
◼ Sleep duration ◼ Psychomotor retardation
◼ Inconsistent findings for
◼ Anger ◼ Melancholia ◼ Cycle Duration
◼ Age at Onset: bipolar 6 years earlier then unipolar (but
◼ Depressed patients with hx of manic episodes
◼ more rapid course changes
◼ Increased number of depressive episodes in bipolar; Roy-
Byrne et al., 1985
◼ Increased puerperal episodes ◼ increased vulnerability to environmental challenges??
◼ In well controlled studies, unipolar depression
◼ Functional imaging studies suggest similar limbic
◼ Similar monoamine levels during episodes. ◼ No difference in episode severity (Ahearn & Carroll,
◼ No diff in psychosocial stressors
◼ life events (Hirschfeld & Cross, 1982) ◼ Stress before suicide (Isometsa et al., 1995) ◼ Low social support
◼ No diff in personality traits
◼ Neuroticism equally associated with unipolar and bipolar
depression but not mania (Lozano & Johnson, 2001)
◼ Cognitive style
◼ Same phenomenology during episode
◼ Negative cognitive style ◼ Low self esteem ◼ Attributions of failure
◼ 12 Weeks Skills-Based Open Group
◼ 12, 2-hour sessions
◼ Led by two psychology interns ◼ 1st hour – week in review ◼ 2nd hour – new skills
◼ 11, mid-week 15-minute coaching calls
◼ Troubleshoot obstacles to skill implementation ◼ Increase motivation and adherence to treatment
◼ 4 modules od 3 sessions each
◼ Module 1 – Behavioural Activation ◼ Module 2 – Thought Defusion and Distress Tolerance ◼ Module 3 – Challenging Thoughts ◼ Module 4 – Interpersonal Skills ◼ Patients can enter the group at the beginning of each module
◼ Measurement Based Treatment
◼ Pre questionnaires:
◼ Personality Inventory MCMI moving to PID-5 (plan is to eventually move to
PID-5 BF)
◼ Treatment Motivation Questionnaire ◼ CUDOS ◼ CUXOS
◼ Weekly measures
◼ CUDOS ◼ CUXOS
◼ Post questionnaires:
◼ PID-5 ◼ CUDOS ◼ CUXOS
Session 1 – Behavioural Activation Session 2 - Values and Goals Session 3 – Sleep Session 4 – Introduction to Mindfulness Session 5 – Distress Tolerance I Session 6 – Distress Tolerance II Session 7 – Introducing Emotions Session 8 – Emotion Regulation I Session 9 – Emotion Regulation II Session 10 – Assessing Your Interpersonal Universe Session 11 – Interpersonal Relationships I Session 12 – Interpersonal Relationships II
BA TW-Defusion Workbook CBT-Challenge Interpersonal
Diagnosis Referral Source Gender Age CUDOS Pre CUXOS Pre 8 Unipolar 7 MDP, 1 DH 5 M, 3 F Range 29-52 AVG 39.6 35.5 33.6 3 Bipolar 3 MDP 1 M, 2 F Range 39-51 Avg: 43.3 28.3 17
0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 1 2 3 4 5 6 7 8 9 10 11 12 Total CUDOS CUXOS ◼
Cudos: pre post t-test <.001 d = 1.3
◼
Cuxos: pre/post t-test <.01 d = .71