Anne Washington Derry 1927 Oil on canvas

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Mood Disorders
M
Anne Washington Derry (1927) Oil on canvas by
Laura Wheeler Waring(1887 - 1948)
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Mood Disorders Outline of Lectures

• Description of Mood Disorders
• Etiological Theories Major Depression
• III. Treatment Major Depression

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Mood Disorders

• Depressive Disorders
• Mania

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Depressive Disorders

• Major Depressive Disorder (single, recurrent)
• Major Depressive Disorder Postpartum onset
• Dysthymic Disorder
• Double Depression
• Postpartum depression will be presented
  separately in a single lecture. Can also be a
  specifier for bipolar disorder.

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Major Depressive Disorder Diagnostic Criteria

• 5 of following symptoms, must include one of
  first two, occurred almost every day for two
  weeks
• Depressed mood
• Pleasure or interest/ Loss
• Appetite
• Sleep disturbance, too much or too little
• Agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Difficulty concentrating or deciding
• Recurrent thoughts of death

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Depressive Symptoms MnemonicSpace Drags
S leep disturbance P leasure/interest (lack of) A
gitation C oncentration E nergy (lack of)/fatigue
D epressed mood R etardation movement A ppetite
disturbance G uilt, worthless, useless S uicidal
thought
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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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Bipolar Disorders

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder

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Manic Episode Diagnostic Criteria

• A distinct period of abnormally and persistently
  elevated, expansive, or irritable mood
• Mood disturbance plus three of the following
  symptoms (four if the mood is only irritable)
• Inflated self esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure to keep
  talking
• Flight of ideas, or racing thoughts
• Distractibility
• Increase in goal directed activity
• Excessive involvement in pleasurable activities
• Marked impairment
• No psychosis
• Not organic

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Hypomania Diagnostic Criteria

• All the criteria of a Manic episode except
  criterion C (marked impairment)

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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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Mood Disorders Summary

• Depressive Disorders
• Major Depressive Disorder (single, recurrent)
• Major Depressive Disorder Postpartum onset
• Dysthymic Disorder

• Bipolar Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder

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Mood Disorders Prevalence

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

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

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Major Depressive Disorder Etiological Theories

• Biological (genetic, brain structures,
  neurotransmitters)
• Behavior and cognition
• Emotion
• Social and cultural factors
• Developmental factors

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Major Depression Genetics

• Family studies
• Relatives of those with a mood disorder are two
  to three times more likely to have a mood
  disorder (usually major depression)
• Twin studies
• If one identical twin has a mood disorder the
  othe twin is 3 times more likely than a fraternal
  twin to have a mood disorder (particulrly for
  bipolar disorder)

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Major Depression Genetics

• Severe mood disorders may have stronger genetic
  contribution than less severe disorders
• Heritability rates are higer for females

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Major Depression Neurotransmitters

• Low levels of serotonin deregulates the activity
  of other neurotransmitters
• Permissive hypothesis

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Major Depression Endorcrine System

• Elevated cortisol

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Major Depression Cognition

• Learned helplessness (Seligman)
• Negative cognitive styles (Beck)

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Learned Helplessness

• Attribution of lack of control over stress leads
  to anxiety and depression
• Depressive attributional style is internal,
  stable, and global

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Negative Cognitive StylesAaron Beck

• Depression is the result of negative
  interpretations (wearing gray instead of rose
  colored glasses, e.g. Eyore in Winnie the Pooh)
• Key Components of Negative Interpretations
• Maladaptive attitudes (negative schema)
• Automatic thoughts
• Cognitive triad
• Errors in thinking

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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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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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Major Depression Developmental Factors

• Children
• Teens
• Elderly

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Treatment Major Depression Overview

• Biological Treatments
• Medication
• ECT
• Special note about antidepressants and children
• Psychological Treatments
• Cognitive Therapies
• Interpersonal Psychotherapy (IPT)
• NIMH Collaborative Treatment Study

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Biological TreatmentMedications

• Tricyclic antidepressants
• Monoamine oxidase (MAO) inhibitors
• Selective serotonin uptake inhibitors
• St. Johns Wort
• ECT (will cover in discussion section)

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Antidepressant Medication with Children

• The effectiveness of antidepressant medication
  with children is questionable.
• December 2003 British drug regulators told
  physicians to stop writing perscriptions for all
  but one of the newer generation of antideressant
  drugs to treat children under 18.
• Benefit did not outweigh the risks (including
  suicidal thoughts and behavior and agression)
• Prozac was exempted.

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Controversy

• Pro Medication
• Cost of untreated depression is high
• Depression itself is lethal (particularly in
  teens)
• Indisputable proof that it works in their own
  clients
• Questioned the adequacy of the studies

• Anti Medication
• Review of 11 studies of effects of medication in
  children revealed that the risks outweigh the
  benefits
• Evidence based practice is guided by the results
  of research not clinicians opinions

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Psychological Treatments

• Cognitive-Behavioral Treatment
• Interpersonal Therapy

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Which treatment is best?
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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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Special Topic 1

• Childhood Onset Depression

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Childhood Onset DepressionHistorical Aspects

• Initial View
• Psychoanalytic developmentally children could
  not experience depression
• Sadness results from loss of valued object/person
• Sadness results in hostility and aggression
• Depression is result of inward hostility
• Children lack superego development to direct
  aggression toward self

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Childhood Onset Depression Historical Aspects

• Initial View
• Clinical findings of Rene Spitz

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Childhood Onset Depression Historical Aspects

• Early View
• Masked Depression
• Later rejected
• Difficult to verify
• Depressive symptoms were evident

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Current Childhood Onset Depressive Disorders

• Adjustment Disorder with Depressed Mood
• Dysthymic Disorder
• Major Depression
• Bipolar Disorder

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Adjustment Disorder with Depressed Mood

• Short-term
• Emotional or behavioral problems
• Reaction to identified stressor

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Special Topic 2

• Suicide

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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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Suicide A Sociological TypologyEmile Durkeim

• Formalized or altruistic suicide
• Egoistic suicide
• Anomic suicides
• Fatalistic suicide

• Sanctioned suicide
• Disintegration of social support
• Major disruption
• Loss of control of ones destiny (mass suicides)

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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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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 DepressionSpecial Topic 3

• See separate Power Point presentation