QUESTIONS AND ESSAY PLANS
1. Discuss the issues raised in the classification and diagnosis of depression. (25 marks)
When answering this question you must not spend much time describing the features
of the classification systems, since the question concerns reliability and validity and
does not require you to describe the systems.
Paragraph 1 Introduction
Give a very brief introduction to what a classification system is and its main
purposes (to enable clinicians to organise data, to provide a summary of the main
syndromes, to keep statistics, as the first step in treatment). Keep it as brief as
possible. Then mention the two main systems in use at present, DSM-IV and ICD-10.
Explain how they are very similar in their classification of depression.
Paragraph 2
Describe what is meant by reliability in the context of a classification system—
essentially, the extent of agreement between clinicians and therefore consistency in
diagnosis. Outline what is necessary to achieve reliability—“tight” and precise
descriptions of each category of mental disorder. Similarly, describe what is meant
by validity (i.e. accurate diagnosis) and mention why it is more difficult to establish
than reliability. Reliability is not necessarily hard to achieve—the problem is that it
is often done at the expense of validity, i.e. diagnosis could be consistently wrong!
So, essentially, it is difficult to achieve both reliability and validity, but not
necessarily difficult to achieve reliability (although, needless to say, this is pointless
without validity).
Paragraph 3
Discuss how the different types of depression raise issues in terms of reliability and
validity of classification. For example, discuss the distinction between endogenous
and reactive depression and the fact that there is no clear dividing line between
minor and major depression and so it is not always possible to use these labels.
Then move on to the issues of a categorical approach. Discuss how comorbidity and
the subjectivity of diagnosis raise further issues in terms of the reliability and
validity of diagnosis.
Paragraph 4
Discuss the reliability and validity of clinical interviews. Outline the semi-structured
interviews for depression, the Structured Clinical Interview for DSM-IV-Patient
Version (SCID-I/P), and the Anxiety Disorder Interview Schedule for DSM-IV (ADISIV). Use Ventura et al. (1998) and Brown et al. (2001) as evidence for reliability and
validity. However, there are some issue. Discuss why ADIS-IV was found to be less
reliable for anxiety disorders.
Paragraph 5
Discuss why both diagnostic interviews and DSM-IV and ICD-10 have content
validity. Next, introduce criterion validity as being assessed by whether those
diagnosed with depression differ in predictable ways from those who do not have
depression. Consider how on the one hand this is true but on the other it is true of
mental disorders in general, not just depression.
Paragraph 6
Explain construct validity and use the low levels of serotonin and the lack of
involvement of people with depression in pleasurable activities. The successful use
of treatments that relate to possible causes such as cognitive distortions also
supports good construct validity.
Paragraph 7
Consider the problems of reliability and validity in terms of gender bias. Discuss the
fact that females are twice as likely to be diagnosed with depression as males and
the arguments against why this is not necessarily bias in diagnosis.
Paragraph 8 Conclusion
Conclude by mentioning the importance of classification systems but the inevitable
problems establishing reliability and validity at the same time. Both DSM and ICD
have been criticised for sacrificing validity on the altar of reliability. Nevertheless,
validity is impossible without reliability, so it is understandable that there has been
a concentration on reliability, which has improved with each subsequent edition.
However, the establishment of a classification system must always be seen as a
work in progress. The challenge now is to attempt to establish not only high
reliability but high validity.
2. “There are many different kinds of depression, for example, unipolar and bipolar,
endogenous, and reactive.”
Discuss explanations for depression, including the evidence on which they are based.
(30 marks)
You need to make sure that your answer addresses the quote, i.e. consider the need to explain the different
types of depression
Paragraph 1 Introduction
Use the quote, i.e. show you understand unipolar, bipolar, endogenous, and reactive.
Perhaps identify other types, e.g. PMS, PPD, and consider that explanations may vary
for these different types of depression.
Paragraph 2
The biological model suggests a genetic basis, which means that different genes may
predispose different types of depression. Give the evidence for unipolar depression,
e.g. Allen (1976), Gershon (1990), and Wender et al. (1986), and then evaluate using
the research evidence against and the criticisms. The evidence for bipolar is
stronger as concordance rates are higher, which supports the idea that the different
types of depression are predisposed by different genes. But question whether this is
a cause as an individual may have the predisposition but never develop the
disorder. Cover this in depth. You could the evolutionary explanations as further
evidence of a genetic basis.
Paragraph 3
The genes may result in biochemical imbalances. Outline Kety’s (1975) permissive
amine theory. Give the research evidence for this based on the biochemical
compounds found in depressives’ urine and the action of antidepressants. Use the
research evidence against as evaluation—they do not work for everybody and take
time to relieve the symptoms. Criticise using the treatment aetiology fallacy and the
issue of cause and effect. Cover this in less depth.
Paragraph 4
Hormonal explanations have also been suggested. Explain the evidence on cortisol.
PMS and PPD also support fluctuating hormone levels as a cause of depression.
Statistics on female mental hospital admissions support this, as 41% were admitted
on the first day or within a day of starting their period. Women are two to three
times more likely to be diagnosed as depressed as men, which may be due to the
role of hormones. However, postmodernists argue that PMS is in part socially
constructed and the diagnosis of depression in more women than men is due to
social factors and gender bias rather than biological factors. Consider the
generalisability of the hormone explanation. Is it more relevant to PMS and PPD
than other types of depression?
LINK SENTENCE: The biological explanations and research evidence have many
weaknesses and so lack conviction as a comprehensive explanation. They are
reductionist and deterministic—explain why. They ignore the role of nurture and so
it is necessary to consider the psychological explanations to gain a fuller
understanding of depression. You need a link sentence like this to ensure that your
content on the alternative explanations is RELATED to the questions.
Paragraph 5
Outline the behavioural explanation, including Lewinsohn’s (1974) and Seligman’s
(1975) research. Cover this in less depth and evaluate that these may be an effect
rather than a cause of being depressed. Consider the reductionism and determinism
of behavioural explanations and use the role of cognitive factors to illustrate this, i.e.
it is not learned helplessness that causes depression but the perceptions and
interpretations that lead to learned helplessness.
Paragraph 6
Outline Abramson et al.’s (1978) attribution model and Beck and Clark’s (1988)
cognitive triad and errors in logic. Cover this in depth, so consider fully the research
evidence for and against and the criticisms. Research does show that emotion and
cognition are interrelated and that the influence is bi-directional as they influence
each other, which lends some support to a cognitive basis to depression. But it also
supports the criticism that cognitive dysfunction is a result of the depression.
Conclude that cognition is likely to be a predisposing factor but a key limitation is
that it is more descriptive than explanatory as this doesn’t explain how or why the
faulty cognition developed. Is this a result of experience of learned helplessness or is
there a biological basis to this, or a social basis?
Paragraph 7
Discuss Freud’s explanation and consider it as a possible cause of faulty cognitions.
We may be victims of our feelings, which determine our cognition. The influence of
social experiences is supported by the research on life events. Consider the
methodological weaknesses of Freud’s and the life events research.
Paragraph 8
Consider whether the different explanations are more relevant to the different types
of disorder, for example, the greater role of biological factors in endogenous
depression and the greater role of life events in reactive depression. Then assess
whether such a classification is possible, as it is oversimplistic and ignores the fact
that depression is likely to be due to an interaction of internal and external factors.
For example, three times as many women are likely to be diagnosed with depression
as men, which may be a form of reactive depression to their role in society or it may
be due to biological differences. We need to consider “sick society” not just the “sick
individual”. Thus, a multi-dimensional approach such as the diathesis–stress model
is needed, as at present understanding is limited as to how the many predisposing,
precipitating, and perpetuating factors interact and how these differ depending on
the type of depression. Thus, an idiographic (individual focused) rather than a
nomothetic (universal focused) approach may be preferable. Whilst a nomothetic
approach is useful in identifying generalisable causes, such universal explanations
may have limited relevance to individual cases. An idiographic approach may be
better able to explain how the different factors interact and so give rise to different
forms of the disorder.
3(a) Outline one or more psychological therapy(ies) for depression. (9 marks)
Note the question is divided into AO1 in part (a) and AO2 in part (b).
Paragraph 1
Introduce psychoanalysis and outline Freud’s methods, such as free association and
dream analysis.
Paragraph 2
Decide if you have time to explain the role of transference. Describe how modern
psychodynamic therapy has moved away from Freud’s original approach in terms of
more focus on social relationships and less on childhood experiences.
Paragraph 3
Outline cognitive therapy as introduced by Aaron Beck and how cognitive therapists
have expanded upon their original approach to include the behavioural element,
thus recognising the interconnectedness of cognition, emotion, and behaviour.
(b) Evaluate the therapy(ies) described in (a). (16 marks)
Paragraph 1
Consider the effectiveness of psychodynamic therapy, for example in treating major
depressive disorder. Use empirical evidence such as Leichsenring (2001).
Paragraph 2
Consider the limited effectiveness for bipolar disorder, such as Colom et al. (1998).
But balance this with the fact it has been found to improve compliance with drugs,
as found by Sajatovic et al. (2007). Discuss the appropriateness of psychodynamic
therapy, such as the cognitive nature of the treatment and the fact the modern form
focuses on current problems. However, discuss the limitations to appropriateness,
such as the fact it ignores motivational factors and behavioural problems.
Psychodynamic therapy requires the patient to be active and articulate and so may
be more relevant to some than others; explain YAVIS. Discuss other factors such as
the fact the therapy is slow-acting and consequently the drop-out rate can be high
because it takes time and effort.
Paragraph 3
Introduce the strong empirical support for cognitive therapy, such as Elkin (1994).
Assess the therapy as curative not just palliative, which means the effects are longlasting and patients are less likely to relapse back into depression. Consider how, in
terms of treating the causes, CBT compares well to other therapies. Discuss the
evidence that CBT is moderately effective for bipolar disorder, such as Lam et al.
(2000) and that the evidence has reliability because Jones (2004) also found CBT to
have moderate effectiveness.
Paragraph 4
Discuss the appropriateness of CBT, including evidence for such as the cognitive
nature of depressive symptoms and the advantage of combining features of
cognitive therapy and behavioural therapy. However, consider issues against
effectiveness such as the fact cognitions may be realistic rather than faulty and the
effects of changing faulty cognitions may be exaggerated.
Paragraph 5
Discuss the fact that the psychological therapies show that depression can be
treated with more than just drugs, and increasingly CBT is being used. But discuss
how comparisons of the effectiveness of different treatments should be treated with
caution due to issues such as individual differences of the patient or therapist, the
“general therapy effect”, the “hello-goodbye effect”, and publication bias. Consider
the ethical issues of therapy such as informed consent and confidentiality. Conclude
that the optimal approach to treatment is a multi-dimensional one in which drugs
are combined with one or more other treatments.