bipolar & depressive disorders

difference between mania and hypomania

both require 3 symptoms, but mania is 1 week and hypomania is 4 consecutive days and doesn’t result in marked impairment or a need for hospitalization, and does not include psychotic features.

diagnostic criteria for a depressive episode

5+ symptoms with at least 1 being depressed mood or loss of interest or pleasure in most or all activities. for 2+ weeks and causes significant distress and/or impairment in functioning

bipolar 1 criteria

at least 1 manic episode (3+ symptoms for 1 week) that may or may not have been preceded or followed by a major depressive or hypomanic episode

bipolar 2 criteria

at least 1 hypomanic episode (3+ symptoms for 4 days) and at least 1 major depressive episode (5+ symptoms for 2+ weeks, at least one being depressed or anhedonic)

cyclothymic disorder diagnostic criteria

numerous periods of hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode. 2+ years for adults and 1 year for children/adolescents

heritability rates for bipolar disorder

60-90%

which disorder has a heritability rate of 60-90%

bipolar

monozygotic and dizygotic concordance rates for bipolar

40-80% monozygotic

4-30% dizygotic

may have higher concordance rates for female twins

which is more heritable, bipolar 1 or 2

bipolar 1

people with bipolar disorder have reduced grey matter volume in these brain areas

PFC, cingulate cortex, hippocampus (but increased volume in lateral ventricles)

environmental risk factors for bipolar

early parent death, child maltreatment (especially emotional abuse), medical comorbidity (IBS, migraines), cannabis/cocaine/other substances, highly stressful life events

difference between mania and ADHD

ADHD - dysphoric mood, low self-esteem, don’t have acceleration of thoughts, fatigue after loss of sleep, may not have increased sexual activity but has higher rates of sexual disorders/risky sexual behavior

mania - elevated or irritable mood, increased self-esteem, distractibility from thought acceleration, decreased need for sleep without physical discomfort, increased sexual activity

difference between manic symptoms in youth vs adults

both have racing thoughts, grandiosity, decreased need for sleep, but:

youth: elated mood and hypersexuality

adults: euphoric or irritable mood

psychosocial interventions for bipolar

psychoeducation, interpersonal and social rhythm therapy, CBT, family-focused therapy (because families with high expressed emotion can cause relapse)

classic bipolar disorder

low likelihood of mixed mood states and rapid cycling, long periods of recovery between episodes, and onset between 15-19

low likelihood of mixed mood states and rapid cycling, long periods of recovery between episodes, and onset between 15-19

classic bipolar

atypical bipolar

mixed mood states, rapid cycling, lack of full recovery between episodes, onset between 10-15

mixed mood states, rapid cycling, lack of full recovery between episodes, onset between 10-15

atypical bipolar

meds for bipolar

lithium for classic bipolar, anticonvulsants and antipsychotics for atypical bipolar, usually not antidepressants because they aren’t effective long term (especially TCAs) and can trigger mania or rapid cycling

difference between atypical bipolar and bipolar with atypical features

atypical features = mood reactivity and at least 2 symptoms (weight gain or increased appetite, hypersomnia, leaden paralysis, or interpersonal rejection sensitivity)

atypical bipolar = mixed mood and rapid cycling, not much recovery between episodes, onset between ages 10-15

persistant depressive disorder

depressed mood with 2 symptoms (poor appetite or overeating, insomnia or hypersomnia, hopelessness), for 2 years in adults of 1 year in children/adolescents

depressed mood with 2 symptoms (poor appetite or overeating, insomnia or hypersomnia, hopelessness), for 2 years in adults of 1 year in children/adolescents

persistant depressive disorder

5 symptoms of depression with at least one being depressed mood or anhedonia, 2 weeks

MDD

MDD

5 symptoms of depression with at least one being depressed mood or anhedonia, 2 weeks

DMDD

1 year of temper outbursts (verbal or behavioral) 3x/week and irritable/angry mood nearly all day every day and observable to others

1 year of temper outbursts (verbal or behavioral) 3x/week and irritable/angry mood nearly all day every day and observable to others

DMDD

what happens when someone meets criteria for both MDD and PDD

both diagnoses are given, and PMDD specifier (with major depressive episode; with intermittent major depressive episodes with current episode, with intermittent major episodes, without current episode

MDD specifier “with peripartum onset”

onset of symptoms occurs during pregnancy or within 4 weeks after delivery

what % of women experience peripartum onset of MDD

80% experience baby blues (sad, irritable, anxious) but smaller percent meet criteria for MDD. of those who do develop MDD, 50% experienced symptoms prior to delivery

psychosocial interventions for MDD with peripartum onset

CBT and interpersonal therapy

meds for MDD with peripartum onset

antidepressants (especially sertraline), but must consider if pregnant or breastfeeding, and impact of a mom with untreated depression for herself and her child

research on exercise and MDD with peripartum onset

exercise may help, but exercise with co-interventions is significantly more effective and exercise alone has a significant effect on symptoms

symptoms of SAD

hypersomnia, overeating, weight gain, or craving for carbs

5 depressive symptoms for 2 weeks, depressed mood or anhedonia, hypersomnia, overeating, weight gain, or craving for carbs

SAD

treatment for SAD and why it works

phototherapy reduces melatonin (SAD = low serotonin + high melatonin)

gender ratio of depression

similar rates in boys and girls during childhood, but the rate for females increases in adolescence while the rate for males remains stable. female adolescents and adults are 1.5-3x more likely

MDD concordance rates

30-50% (46% monzygotic and 20% dizygotic). concordance rates may be higher for female twins

personality trait linked to MDD

neuroticism explains a large portion of the genetic contribution

neurotransmitters involved in MDD

low serotonin, dopamine, norepinephrine

people with MDD have reduced grey matter in which brain areas

dorsolateral PFD, medial PFC, orbitofrontal PFC, cingulate cortex, caudate nucleus, hippocampus, thalamus (but increased volume in lateral ventricles)

how is the HPA axis involved in MDD

hyperactivity in HPA (hippocampus-pituitary-adrenal) axis, often due to chronic stress especially in early life, which causes increased cortisol which contributes to emotional and cognitive symptoms of depression because it reduces hippocampus volume that, in turn, causes memory problems and other cognitive deficits

Lewinsohn’s social reinforcement theory

depression is the result of low rate of response-contingent reinforcement for social behaviors due to a lack of reinforcement in the environment and/or poor social skills, which results in isolation, low self-esteem, pessimism), which further decreases the likelihood of positive reinforcement in the future

which theory posits that depression is the result of low rate of response-contingent reinforcement for social behaviors due to a lack of reinforcement in the environment and/or poor social skills, which results in isolation, low self-esteem, pessimism), which further decreases the likelihood of positive reinforcement in the future

Lewinsohn’s social reinforcement theory

Seligman’s learned helplessness model

depression is the result of repeated exposure to uncontrollable negative life events that result in helplessness (especially attributing negative events to stable, internal, and global factors)

which theory posits that depression is the result of repeated exposure to uncontrollable negative life events that result in helplessness (especially attributing negative events to stable, internal, and global factors)

Seligman’s learned helplessness model

Beck’s cognitive theory

depression is the result of a negative cognitive triad (negative thoughts about oneself, the world, and the future)

which theory posits that depression is the result of a negative cognitive triad (negative thoughts about oneself, the world, and the future)

Beck’s cognitive theory

differences in depression symptoms based on age

older adults are less likely to have affective symptoms and more likely to have somatic symptoms, cognitive changes, and anhedonia

differences in depression symptoms based on cultural background

latino, mediterranean, middle eastern, asian, and other non-western cultures report more somatic symptoms than members of western cultures, who report more psychological symptoms

who is more likely to report somatic symptoms of depression vs psychological

older adults and members of non-western cultures

MDD comorbidity

most common is substance use disorder (specifically alcohol use disorder), followed by anxiety then personality disorder. it also linked to sleep problems, substance use, heart disease, stroke, diabetes, etc. The risk between MDD-health problems is bidirectional.

how does MDD impact sleep

prolonged sleep latency (longer time falling asleep), reduced REM latency (short time between sleep onset to REM), reduced slow-wave (stages 3 and 4), increased REM density (more rapid eye movements per unit of time).

which disorder causes prolonged sleep latency (longer time falling asleep), reduced REM latency (short time between sleep onset to REM), reduced slow-wave (stages 3 and 4), increased REM density (more rapid eye movements per unit of time).

MDD

difference between meds and therapy in treating MDD

in adults, combined meds + therapy is more effective than either therapy alone or meds alone. there is no difference in effectiveness between only doing therapy and only doing meds.

MDD treatment in children

insufficient evidence to recommend any particular psychosocial or pharmacological

MDD treatment in adolescents

CBT or interpersonal therapy for adolescents (IPT-A), and fluoxetine as the first-line medication. but there is insufficient evidence to recommend either (psychotherapy or fluoxetine) over the other.

MDD treatment in adults

either therapy or second-generation antidepressant (SSRI or SNRI) as the initial treatment, and there is no recommendation for either over the other for initial treatment. recommended therapies are CBT, MBCT, IPT, behavioral therapy, psychodynamic therapy, and supportive therapy. The combination of CBT or IPT + med is most appropriate for chronic or treatment-resistant depression, but leave it up to the clinician to determine a combined treatment is desirable in other situations. (although there is evidence that combined is more effective)

MDD treatment in older adults

group-CBT or combination of IPT and a second generation antidepressant. insufficient evidence for recommending self-guided bibliotherapy or life review therapy.

newer or second-line treatments for MDD

St. John’s wort, ketamine, TGAs (ariprprazole, brexiprazole, cariprazine), pramipexole (usually used for Parkinson’s and RLS), ECT, repetitive transcranial magnetic stimulation (rTMS), exercise (especially aerobic)

research on St. John’s wort for MDD

similar effects as SSRIs for mild and moderate depression, with lower dropout rates and fewer side effects. but not effective for severe depression and interacts with other drugs (especially SSRIs because it also increases serotonin, and it reduces the effectiveness of alprazolam, bupropion, and immunosuppressants)

research on ketamine for MDD

effective as a fast-acting treatment for treatment-resistant depression and suicidal ideation. works by increasing glutamate and is prescribed as a nasal spray (esketamine) in conjunction with an antidepressant.

antipsychotics used to augment SSRIs/SNRIs for treatment-resistant depression, and how they work

TGAs aripiprazole, brexipiprazole, cariprazine (although some consider them SGAs). work as partial agonists at dopamine receptors where levels are too low.

research on pramipexole for MDD and how it works

usually used for Parkinson’s and RLS, used off-label for treatment-resistant unipolar depression and treatment-resistant bipolar depression. dopamine agonist (increases)

research on electroconvulsive therapy (ECT) for MDD in terms of effectiveness

high success rate for severe depression but only used when other meds don’t work or the severity of symptoms requires a quick response. has a higher success rate, higher remission rate, and faster time to remission

response and remission rates for ECT for MDD and how they compare to therapy and meds

response rate 80% remission rate 70%, compared to 30-60% for therapy and 25-45% for meds.

time of remission for ECT compared to therapy and meds

remission in 1-3 weeks (therapy 6-10 weeks for CBT and IPT; meds 4-12 weeks)

disadvantages of ECT for depression

anterograde (new memories) and retrograde amnesia. anterograde amnesia resolves in a few weeks. retrograde amnesia impacts recent memories more than remote. retrograde amnesia resolves in weeks to several months, but many continue to experience gaps in memory. it’s more severe with bilateral placement (compared to right unilateral), and when there’s a large number of sessions and short time between sessions.

what does repetitive transcranial magnetic stimulation (rTMS) for MDD involve

noninvasive technique that uses a magnetic field to stimulate the left dorsolateral PFC

advantages and disadvantages of rTMS for MDD

effective for treatment-resistant depression and doesn’t require sedation or cause memory loss, but has a lower response and remission rate than ECT

differences between virtual and in-person therapy in terms of effectiveness for MDD

no difference in terms of symptoms, quality of life, client satisfaction, or therepeutic alliance

research on exercise as treatment for MDD

reduces depressive symptoms even when the level is lower than public health recommendations. may have similar effectiveness as therapy and meds for mild to moderate depression, and adding exercise to therapy and meds makes them more effective.

why does aerobic exercise help depression

beneficial impact on cognitive functioning (executive functioning, reward processing) that are ordinarily impaired in people with this disorder

in what populations is NSSI more common

highest in gender minorities (especially transgender), followed by sexual minorities (especially bisexual). also more common in adolescents followed by young adults

onset of NSSI

12-15

the 11th leading cause of death for all age groups combined but is the 2nd leading cause for adolescents and young adults

suicide

suicide is the _(#)_ cause of death for which age groups

11th leading cause for all age groups combined

2nd leading cause for ages 10-14, 15-24, and 25-24

gender ratio and ages for rates of suicide

4x higher in males (for males, highest rate is for ages 75+; and for females, highest rate is for ages 45-64)

rates of suicide based on culture

for both males and females, rates are highest for non-hispanic and american indian/alaskan natives

rates of suicide for veterans vs non-veterans

34.7 per 100,000 (vs 17.1)

rates of suicide of previously incarcerated individuals

higher than nonincarcerated, and men and women have equal rates (instead of men being higher like usual) because rates among recently released women are 3x higher than recently released men

rates of SI and suicide attempts in transgender adults vs cisgender adults

81% and 42% vs 35% and 11%

trans vs cisgender rates of suicidal ideation

in order: transgender women, transgender men, cisgender women, cisgender men

depression is associated with hyper/hypoactivity in ___ and hyper/hypoactivity in ___

hyperactivity in vmPFC and hypoactivity in dlPFC