Mood Disorders: Depression, Mania,

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Mood Disorders Depression, Mania, Bipolar
Disorder
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What is Mood?

• Mood is a a conscious state of mind or
  predominant emotion
• Websters Dictionary

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What is a Mood Disorder?

• Involves disabling disturbances in emotions that
  are markedly different from normal functioning
• Can also include cognitive behavioral
  disturbances
• Generally occurs in discrete episodes
• Depression extreme sadness
• Mania extreme elation and irritability

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Types of Mood Disorders

• Main Distinction unipolar or bipolar
• Unipolar only one end of the emotion spectrum
• Major Depressive Episode
• Manic Episode
• Bipolar cycling between both ends of the emotion
  spectrum
• Bipolar Disorder
• Other Disorders
• Dysthymia mild, chronic form of depression
• Cyclothymia similar to bipolar, but a more mild
  form of mania (hypomania)

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Bipolar Disorders

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder

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Manic Episode DSM Criteria

• A distinct period of abnormally and persistently
  elevated, expansive, or irritable mood, lasting
  at least 1 week (or any duration if
  hospitalization is necessary).
• During the period of mood disturbance, three (or
  more) of the following symptoms have persisted
  (four if the mood is only irritable) and have
  been present to a significant degree
• (1) inflated self-esteem or grandiosity
• (2) decreased need for sleep (e.g., feels rested
  after only 3 hours of sleep)
• (3) more talkative than usual or pressure to
  keep talking
• (4) flight of ideas or subjective experience
  that thoughts are racing
• (5) distractibility (i.e., attention too easily
  drawn to unimportant stimuli)
• (6) increase in goal-directed activity or
  psychomotor agitation
• (7) excessive involvement in pleasurable
  activities that have a high potential for
  painful consequences

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Manic Episode Rule-Outs

• do not meet criteria for a Mixed Episode
• Mixed episode both manic and depressed nearly
  everyday for at least one week
• marked impairment in occupational functioning or
  in usual social activities or relationships with
  others, or to necessitate hospitalization to
  prevent harm to self or others, or there are
  psychotic features
• not due to the direct physiological effects of a
  substance (e.g., a drug of abuse, a medication,
  or other treatment) or a general medical
  condition (e.g., hyperthyroidism)
• Note Manic-like episodes that are clearly
  caused by somatic antidepressant treatment (e.g.,
  medication, electroconvulsive therapy, light
  therapy) should not count toward a diagnosis of
  Bipolar I Disorder

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Bipolar I

• 1 or more manic episodes may have had past
  depressive episodes or not
• Lifetime Prevalence about 1 equal in men and
  women
• Course and Prognosis poorer prognosis than MDD
• 45 have one more episode
• only 50-60 achieve control over Sx with lithium
• 40 develop a chronic disorder

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Bipolar II

• recurrent major depressive episodes with
  hypomanic episodes
• Hypomania - All the criteria of a Manic episode
  except criterion C (marked impairment)
• NOT full-blown manic episodes, if an individual
  does experience a manic episode, they are then
  diagnosed with Bipolar I Disorder
• matter of differential diagnosis

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Bipolar Disorder

• Bipolar I
• Alternation of full manic and depressive episodes
• Average onset is 18 years
• Tends to be chronic
• High risk for suicide

• Bipolar II
• Alternation of Major Depression with hypomania
• Average onset is 22 years
• Tends to be chronic
• 10 progess to full biploar I disorder

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Cyclothymia

• For at least two years (one year for children and
  adolescents) presence of numerous hypomanic
  episodes and numerous periods with depressed mood
  or loss of interest or pleasure that did not meet
  criterion A (5 symptoms) of Major Depression
• During a two-year period (1 year in children and
  teens) of disturbance, never without hypomanic or
  depressive symptoms for more than tow months at a
  time
• No evidence of MDD or Manic episode during the
  first two years of disturbance
• No psychotic disorder
• No organic cause

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Mania Etiology

• better-suited for the biological model
• not normally distributed in the population
• Symptoms are very marked and severe
• not necessarily precipitated by a positive life
  event can override negative events
• further evidence in favor of diathesis
• Familial Pattern seen
• Twin and adoption studies

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What Does Mania Look Like?
Client 1 Mary
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Depressive Disorders

• Major Depressive Disorder (single, recurrent)
• Major Depressive Disorder Postpartum onset
• Dysthymic Disorder
• Double Depression
• Postpartum depression as a specifier

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What Does Depression Look Like?

• Sadness
• Suicidal Thoughts
• Tiredness
• Boredom
• Unwilling to get out
• Insomnia

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Depressive Episode/Disorder DSM Criteria

• Five or more of the following during the same
  2-week period that represent a change from usual
  functioning including either (1) depressed mood
  or (2) loss of interest.
• Sad, depressed mood, most of the day, nearly
  every day for two weeks
• Loss of interest and pleasure in usual activities
• Difficulties sleeping
• Shift in activity level
• Changes in appetite and weight loss/gain
• Loss of energy, fatigue
• Negative self-concept, self-blame, guilt,
  worthlessness
• Difficulty concentrating
• Recurrent thoughts of death or suicide

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Depression Diagnosis Rule-Outs

• The symptoms do not meet criteria for a Mixed
  Episode
• The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• The symptoms are not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition (e.g., hypothyroidism).
• The symptoms are not better accounted for by
  Bereavement, i.e., after the loss of a loved one,
  the symptoms persist for longer than 2 months or
  are characterized by marked functional
  impairment, morbid preoccupation with
  worthlessness, suicidal ideation, psychotic
  symptoms, or psychomotor retardation.

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Major Depression

• MDD, Single episode
• Absence of mania or hypomania

• MDD, Recurrent
• 2 major depression episodes, separated by at
  least a 2 month period with more or less normal
  functioning/mood

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Dysthymic Disorder Symptoms

• Depressed/irritable mood
• Presence of two of the following
• Appetite disturbance
• Sleep disturbance
• Low energy/fatigue
• Poor concentration of difficulties making
  decision
• Feelings of hopelessness
• C. Present for two year period (one year in
  children and adolescents)
• D. No evidence of a Major Depressive Epidsode
  during the first two years (one year for
  children)
• E. No manic or hypomanic episode
• F. No chronic psychotic disorder
• G. Not related to organic factors

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Double Depression

• Not a diagnosis
• Meet diagnostic criteria for both MDD and
  Dysthymic Disorder

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Prevalence

• Point prevalence is the percentage of the
  population who have the disorder at a particular
  time or over a given period of time.
• Lifetime prevalence is the percentage of
  individuals who have ever had a specific disorder
  at any time.

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Facts About Depression

• Major depression is the single most common
  psychiatric disorder in the U.S.
• The point prevalence rate over a 1-year period is
  8 for men and 13 for women.
• Lifetime prevalence rate is 12.7 for men and
  21.3 for women.
• In addition, depression is the most common factor
  leading to suicide.

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What Does Depression Look Like?
Client 1 Mary
Client 2 Barbara
Client 3 Evelyn
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Video Reactions?

• What symptoms of depression did you notice in
  these clients?
• Any evidence of suicidal thoughts?
• Which patient might be more likely to commit
  suicide? Why?

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Etiology Biological

• Genetic Factors
• Family, twin, and adoption studies suggest that
  depression in hereditary
• More severe the depression in an individual, more
  likely that relative have depression as well
• MDD concordance 40 MZ, 10 DZ
• Mania concordance 75 MZ, 25 DZ
• Severity of disorder is due to strength of
  genetic loading

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Etiology Biological cont.

• Adoption studies
• More mood disorders occur in the biological
  relatives of those with mood disorders
• both unipolar and bipolar disorders
• severity linked to the strength of the genetic
  loading

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Etiology Biological Cont

• Neurochemical Factors
• Neurotransmitters
• Norepinephrine
• Serotonin
• Dopamine
• Not clear what processes are dysfunctional
  (production, reuptake, chemical breakdown, etc.)
• Neuroendocrine changes
• Hypothyroidisim

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Research on Neurotransmitters

• norepinephrine serotonin
• Implicated in mania and depression
• effectiveness of antidepressants
• most drugs in psychiatry discovered by accident
• Not as simple a relationship as previously
  thought
• E.g. TCA and MAOI drugs
• Permissive hypothesis

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Becks Cognitive Theory of Depression

• distortions of reality depressogenic cognitions
  result in depression
• schema filters and organizes experiences to store
  beliefs and knowledge about ourselves
• cognitive triad of negative schemas
• negative view of the self, the world, and the
  future

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Cognitive Theory Cont

• negative automatic thoughts
• further bias that individuals view of himself,
  the world, and the future
• e.g., arbitrary inference, selective abstraction,
  overgeneralization, magnification, etc.
• thoughts focused on experiences of loss and
  failure
• research supports the presence of distorted,
  automatic cognitions
• the causal relationship of these factors not
  established

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Helplessness/Hopelessness Model

• Seligmans learned helplessness model started as
  a conditioning model with dogs
• those who were exposed to uncontrollable aversive
  situations would develop depression that was
  rooted in feelings of helplessness

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Attributional Model

• Abramson - Attribution of lack of control over
  stress leads to anxiety and depression
• Cognitive distortions affect the interpretation
  of causes of events in peoples lives.
• biased attributional style (i.e., a cognitive
  style regarding beliefs about the causes of
  events) characterized by internal, stable, and
  global attributions.

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Seligman and Beck

• Seligman
• Attributions are
• Internal
• Stable
• Global
• I am inadequate (internal) at everything (global)
  and I always will be (stable).
• Dark glasses about why things are bad
• Interpretation (theory)

• Beck
• Negative interpretations about
• Themselves
• Immediate world (their place)
• Future (their place)
• I am not good at school (self). I hate this
  campus (world). Things are not going to go well
  in college (future).
• Dark glasses about what is going on
• Description

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Attributional Model Cont

• Internal - attribute negative events to own
  failings
• Stable - belief that causes of negative events
  remain constant
• Global - assume causes of negative events have
  broad and general effects
• research supports the hopelessness model
• but cannot establish causal relationship

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Major Depression Social and Cultural Factors

• Stressful life events
• Social support (marital relationship) (see chart)
• Gender
• Culture (see chart)

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Marital Status and MDDPercentage w/MDD
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Ethnicity and Prevalence of MDDPercentage by
Ethnicity
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Gender Differences in Depression

• Dr. Susan Nolen-Hoeksema
• Women diagnosed twice as often as men
• difference not evident in childhood
• boys and girls are just as likely to experience
  depression
• Changes in preteen years
• What factors may be involved in the development
  of these differences?

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Diathesis-Stress Model

• Neither biological nor environmental and personal
  factors alone can produce depression
• a biological vulnerability (or diathesis)
  interacts with life stressors to produce
  depression
• For example, a neurotransmitter dysfunction may
  interact with life stressors (e.g., death of a
  loved one) to produce depression

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Diathesis-Stress Example
Low NE
Depression
Normal NE
No Life Event Life Event
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Comorbidity with Anxiety

• distinguishing depression from anxiety difficult
• Watson Clark tripartite model
• Negative affectivity (NA) - pervasive individual
  differences in negative emotionality and
  self-concept
• Common to anxiety depression
• Anhedonia - lack of experiencing pleasure
• specific to depression
• Anxious arousal - physiological symptoms of
  anxiety
• specific to anxiety disorders

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Psychological Treatments for Depression

• Psychodynamic Therapies
• Cognitive-Behavioral Therapies
• Beck Cognitive Therapy
• Social Skills Training
• Behavioral Activation
• Interpersonal Therapy

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Depression Collaborative Research Program
Cognitive Therapy
Placebo Clinical Management
Interpersonal Psychotherapy
Treatment Groups
Medication Imiprimine
Outcome Measures Depressive Symptoms Overall
symptomotology and life functioning Functioning
in treatment specific domains
Procedures 16 weeks of treatment Extensive
Assessment
T

• Results
• Follow-up-18 months
• Equivalent success in three active treatments
• Only 20 to 30 of recovered patients were still
  well
• Patients in IPT report more satisfaction with
  treatment
• IPT and CBT patients more likely to report that
  treatment affected capacity to establish and
  maintain relationships and to understand source
  of their depression

• Results
• Post-Treatment
• Equivalent success in three active treatments
  over placebo
• Medication was faster
• IPT better than CBT for more severely depressed
  patients
• Particular treatments effected change in expected
  domains

Many Controversial Issues
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Biological Therapies for Depression

• Drug Therapies
• Tricyclics
• Selective serotonin reuptake inhibitors
• Monoamine oxidase inhibitors
• Electroconvulsive Therapy

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Mood Disorders Prevalence

• Disorders
• Major Depression
• Dysthymia
• Bipolar I
• Bipolar II
• MDD (Postpartum)

• Prevalence
• 4.9
• 3.2
• 0.8
• 0.5
• 13

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Suicide

• 8th leading cause of death in the U.S.
• Overwhelmingly white phenomena
• Suicide rates also quite high in Native American
• Rate of suicide is increasing in adolescents and
  elderly
• Males are more likely to commit suicide
• Females are more likely to attempt suicide
  (except China)

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5 Myths and Facts About Suicide

• Myth 1
• People who talk about killing themselves rarely
  commit suicide.

• Fact
• Most people who commit suicide have given some
  verbal clues or warnings of their intentions

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5 Myths and Facts About Suicide

• Myth 2
• The suicidal person wants to die and feels there
  is no turning back.

• Fact
• Suicidal people are usually ambivalent about
  dying they may desperately want to live but can
  not see alternatives to problems.

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5 Myths and Facts About Suicide

• Myth 3
• If you ask someone about their suicidal
  intentions, you will only encourage them to kill
  themselves.

• Fact
• The opposite is true. Asking lowers their anxiety
  and helps deter suicidal behavior. Discussion of
  suicidal feelings allow for accurate risk
  assessment.

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5 Myths and Facts About Suicide

• Myth 4
• All suicidal people are deeply depressed.

• Fact
• Although depression is usually associated with
  depression, not all suicidal people are obviously
  depressed. Once they make the decision, they may
  appear happier/carefree.

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5 Myths and Facts About Suicide

• Myths 5
• Suicidal people rarely seek medical attention.

• Fact
• 75 of suicidal individuals will visit a
  physician within the month before they kill
  themselves.

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Sociodemographic Risk Factors

• Male
• gt 60 years
• Widowed or Divorced
• White or Native American
• Living alone (social isolation)
• Unemployed (financial difficulties)
• Recent adverse life events
• Chronic Illness

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Clinical Risk Factors

• Previous Attempts
• Clinical depression or schizophrenia
• Substance Abuse
• Feelings of hopelessness
• Severe anxiety, particularly with depression
• Severe loss of interest in usual activities
• Impaired thought process
• Impulsivity

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Assessing Risk and Planning Intervention
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Commonalities of Suicide (Schneiderman, 1985)

• purpose is to seek a solution.
• goal is the cessation of consciousness (not
  death).
• stimulus is intolerable psychological pain.
• stressor is frustrated psychological needs.
• emotion is hopelessness-helplessness.
• cognitive state is ambivalence.
• perceptual state is constriction.
• action is egression.
• interpersonal act is communication of intention.
• consistency is with lifelong coping patterns.

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Clinical Considerations of Suicide Assessment

• For those who are reluctant to assess suicide
• Asking questions may feel intrusive but not
  asking has dangerous consequences
• A calm and genuinely concerned approach is
  effective

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SuicideTreatment

• Problem-solving
• Cognitive behavioral therapy
• Coping skills
• Stress reduction

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Postpartum Depression
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Burden

• In the United States, depression is the leading
  cause of non-obstetric hospitalizations among
  women aged 18-44.
• In the year 2000, 205,000 women aged 18-44 were
  discharged with a diagnosis of depression.
• Seven percent of all hospitalizations among young
  women were for depression.

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Perinatal Depression Prevalence
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Postpartum Blues

• Most common, 50-80
• Relatively brief
• Few hours to several days
• Onset usually in first week to 10 days PP
• Typically remit spontaneously
• May represent the initial stages of PPD/PPP

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Typical Blues Symptoms

• Low Mood
• Mood Lability
• Insomnia

• Anxiety
• Crying
• Irritability

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Postpartum Psychosis

• Rare 1/1000 postpartum women
• Hallucinations and/or Delusions
• Risk Factors
• History Bipolar Affective Disorder/Psychosis
• Family history of psychosis
• Having first child
• Aggressive intervention absolutely necessary

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Postpartum Psychosis

• Usually Begins Within 90 Days Postpartum
• Length is Quite Variable
• Prevalence 1/500 to 1/1000
• Family history of bipolar disorder 33/1000
• Family history of postpartum psychosis 22/1000
• Personal history bipolar disorder 1/2
• Sequelae Future Postpartum Psychosis

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Postpartum Depression

• Not as mild or transient as the blues
• Not as severely disorienting as psychosis
• Range of severity
• Often undetected

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Postpartum Depression Risk Factors

• Lower SES/unemployment
• Past depression or anxiety disorder
• Past history of alcohol abuse
• Stressful life-events
• Poor marital relationship
• Inadequate social support
• Child-care related stressors
• African American ethnicity

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Effects of Perinatal DepressionAn Overview

• Depression negatively effects
• Mothers ability to mother
• Motherinfant relationship
• Emotional and cognitive development of the child

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Postpartum DepressionMaternal Attitudes

• Infants perceived to be more bothersome
• Make harsh judgments of their infants
• Feelings of guilt, resentment, and ambivalence
  toward child
• Loss of affection toward child

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Postpartum DepressionMaternal Behaviors

• Gaze less at their infants
• Take longer to respond to infants utterances
• Show fewer positive facial expressions
• Lack awareness of their infants
• Increased risk for abusing children

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Postpartum DepressionMaternal Interactions

• Flat affect, low activity level, and lack of
  contingent responding
• OR
• Alternating disengagement and intrusiveness

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Effects of Maternal Depression

• Infants- lowered Brazelton scores, frequent
  looking away, fussiness
• Toddlers- poorer cognitive development, insecure
  attachment
• Children- cognitive development of low ses boys
• Adolescents-higher cortisol levels

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What Can Be Done?

• ROUTINE SCREENING
• REFERRAL TO TREATMENT

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Why Screen for Perinatal Depression?

• Screening is associated with increased detection
• Georgiopoulos et al., 1999, 2001
• EPDS screening resulted in increased chart-based
  diagnosis of PPD from 3.7 to 10.7 after one
  year of universal screening Rochester, MN

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Barriers to Detection

• Women will present themselves as well as they are
  ashamed and embarrassed to admit that they are
  not feeling happy
• Media images contribute to this phenomena

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Barriers to Detection

• Women will present themselves as well as they are
  ashamed and embarrassed to admit that they are
  not feeling happy
• Tom Cruise Snap out of it mentality
• Media images contribute to this phenomena

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Barriers to Detection (cont)

• Lack of knowledge about range of postpartum
  disorders
• They dont want to be identified with Andrea
  Yeats
• May genuinely feel better when you see them (they
  got dressed, out of house, lots of attention, not
  isolated)

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I Was Depressed But Didnt Know It.

• Commonalities in the Experience of Non-depressed
  and Depressed Pregnant and Postpartum Women
• Changes in appetite
• Changes in weight
• Sleep disruption/insomnia
• Fatigue/low energy
• Changes in libido

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What is Required for Effective Screening?

• What to do with a positive screen?
• Implement or refer for diagnostic assessment
• Arrange for treatment
• Antidepressant medication
• Psychotherapy (individual or group)
• Arrange for follow-up