A Developmental Approach to Depression in Young Adults

1. A Developmental Approach to Depression in Young Adults

2. The Many Relations Between Mind, Relationships and Depression External events External events � Interpersonal Depression Interpersonal functioning functioning � Internal Internal �

3. Heterogeneity by Developmental History in Major Depression in Adults Biology - reduced hippocampal volumes in depression, only in maltreated subgroup (Vythilingam et al, 2002) Treatment response - differential responses to psychotherapy and pharmacotherapy for depression depending on maltreatment history (Nemeroff et al 2003)

4. Juvenile vs Adult Onset Depression Jaffee et al (2002), Dunedin. Prospective, DSM Major Depression past year at ages 11,13,15,18,21,26. �Juvenile Onset� (11,13,15) compared to �Adult Onset� (18, 21,26) Data from birth with assessments at ages 3, 5, 7.

5. Juvenile vs Adult Onset Depression: Child Characteristics Increased comorbid disorders in adolescence to age 15, but not up to age 26 Infancy and early childhood � More perinatal insults, poorer motor skills, inhibited, not undercontrolled temperament Ages 5-9 � Teacher reported peer problems, hyperactivity, antisocial behaviours: self reported depression

6. Juvenile vs Adult Onset: Childhood Adversities, Dunedin

7. Conclude from Dunedin �That juvenile onset depression and its antecedent symptoms proceed across a broad front from early childhood, implicating externalising and internalising symptoms, and social difficulties. Juvenile onset depression has some features in common with antisocial problems e.g. hyperactivity, but accompanied by behavioural inhibition. Adult onset depression not associated with child vulnerabilities nor with family adversities, but is with CSA. �

8. The Wirral Women�s Health Survey Jonathan Hill, Marie Byatt, Elizabeth Burnside, Rachel Davis, Lynn Rollinson, Katie Harvey University of Liverpool UK. Andrew Pickles, School of Epi and Health Sciences, University of Manchester, UK Funded by the Medical Research Council (UK) Hill et al (2001), British .Journal of Psychiatry, 179, 104-109, Hill et al (2004), Psychological Medicine, 34, 1483-1493

9. Recruitment: Questionnaire Screen Questionnaires sent to women aged 25-36 In 5 GP Practices, Socioeconomically Representative Response 60.7% Total Returned 1293 Questions covered recalled contact sexual abuse before age 16, and parental care

10. Interviews All Reporting Child Sexual Abuse (CSA) , Low Parental Care, Random Selection of Neither � Stratified Sample Total 198 Childhood Adversities (CECA) Childhood Psychopathology (RECAP) Adult Psychiatric Disorder (SADS-L) Adult Relationships (APFA)

11. Interview Data Weighted Back to the Questionnaire Sample

12. Estimated Population Prevalences: Childhood Experiences CSA 18.6% (Fergusson and Mullen weighted average 19.1%) Neglect 14.3% Physical Abuse 23.8% Institutional stay 6.1%

13. Estimated Population Prevalences: Psychopathology DSM Major Depression since age 16, 18.4% Depression before age 16, 13.3% Anxiety disorder before age 16, 12.9% Conduct Disorder before age 16, 10.1% ADHD before age 7, 11.5%

14. Distribution of Child and Adult Depression

15. Juvenile Onset Adult Depression Contrasted with No Adult Depression (N = 153)

16. Adult Onset Depression Contrasted with No Adult Depression (N = 168)

17. Juvenile Onset Adult Depression Contrasted with Adult Onset Depression (N = 73)

18. Juvenile Onset Adult Depression Contrasted with Adult Onset: Peers and Pregnancy

19. Possible Mechanism for Delayed Onset Following CSA Affect regulation is effective until start of adult sexual relationships Regulation of affect associated with abuse through general �categoric� memories for negative experiences Generalises to categoric memories for positive experiences Over-generality for positive experiences reduces coping with mood induced self-devaluation Altered reactivity of the HPA axis?

20. DSM Major Depression 21-30: The Role of Quality of Close Relationships

22. Possible Mechanism for Delayed Onset Following CSA Affect regulation is effective until start of adult sexual relationships Regulation of affect associated with abuse through general �categoric� memories for negative experiences Generalises to categoric memories for positive experiences Over-generality for positive experiences reduces coping with mood induced self-devaluation Altered reactivity of the HPA axis?

23. Negative Categoric Memories Protect, Positive Categoric Memories Confer Vulnerabiity

24. Attachment Hypotheses for Depression - Bowlby Inadequate care following death of a parent, Failure to form adequate attachments leading to a model of the self as a failure, The parent conveys that the child is incompetent or unlovable Very little evidence linking AAI attachment status and depression � unpublished negative findings?

25. Depression and Attachment Wirral subsample with rated AAIs, N = 52 Neglect and sexual abuse from the CECA 20/52 (39%) DSM Adult Major Depression 9/52 (17%) Major Depression, Past 5 Years Secure 25, Insecure 27 Secure 25, Insecure 15, Unresolved 12

26. PPC, CSA and Insecure Attachment (Does �earned secure� exist?)

27. Poor Parental Care, Insecure Attachment and Major Depression � The Story Ends Here!

28. Unresolved Loss or Trauma and DSM Major Depression

29. Lack of Resolution Scores and DSM Adult Major Depression 

30. What About the Sexual Abuse Missed in the AAI?

31. AAI Sexual Abuse Questions AAI: Some people have had memories of abuse in the family, did anything like that happen to you? What about outside the family? Did it happen often? i.e. Not specific about sexual abuse, family members not specified, includes extrafamilial abuse.

32. CECA Sexual Abuse Questions When you were a child or teenager, did you ever have an unwanted sexual experience? If no, ask additional screening questions: Has anyone ever tried or succeeded in having sexual intercourse with you against your wishes? When was that? Can you think of any upsetting sexual experiences you had before you were 17? What about a situation where you were nearly involved in an unwanted sexual incident but avoided it?

33. Adolescent Depression, Gender and Emotional Sensitivity (Murray et al) Difficult experience with friend Expression Accessibility Lack of distancing Associated in girls with maternal PND, and 18 months insecure attachment, and with current symptoms of depression

34. Why is such a good thing not so good for girls? Girls may respond to adversity with increased efforts to make interpersonal sense � mobilizing negative emotions, hence activating them Girls may conduct relationships at higher levels of emotionality hence making greater demands on emotion regulation In some girls this may occur in relationships that are not �equipped� to support emotion regulation.

35. Gender, Adversity & Intentionality

37. Gender, Emotion Expression (Upset, Comfort) and Relationship Type

38. In Summary: Development and Depression Probably several developmental pathways to depression Some probably associated with neglect, attachment and processes in close relationships Some probably trauma related affecting emotion regulation and memory Female vulnerability to depression may be associated with high levels of emotional engagement in relationships