Chapter 8: Mood Disturbance:​ Depression and Mania​

Mental Health Social Work Practice in Canada

Depression Spectrum Disturbances​

• Major depressive disorder​

• Persistent depressive disorder​

• Adjustment disorder with depressed mood​

Adjustment disorder with depressed mood​

• Emotional symptoms in response to a stressor evidenced by marked distress out of proportion to the severity/intensity of stressor and/or symptoms result in significant impairment in functioning​

Persistent depressive disorder​

• Characterized by depressed mood which is not as severe as a major depressive episode but extends over a period of at least two years​

Major depressive disorder​

• Presence of one or more major depressive episodes without a history of manic, mixed or hypomanic episodes​

Bipolar Spectrum Disturbances

• Bipolar I disorder​

• Bipolar II disorder​

• Cyclothymia

Cyclothymia

• A period of at least two years with numerous periods of depressed mood, alternating with periods of hypomanic symptoms ​

Bipolar II disorder​

Characteristic major depressive episodes punctuated by at least one hypomanic episode

Bipolar I disorder​

• Presence of one or more manic episodes usually accompanied by major depressive episodes​

Factors Contributing to Disturbances in Mood​

Social/ Environmental:

• Social stressors​

• Seasonality​

• Substance abuse

Biological:

• Genetics​

• Neurobiology​

• Hormones​

Example: Risk Factors for Post-Partum Depression​

• Multiple influences​

• Interpersonal problems particularly with spouse or partner​

• Other stressful negative life events, such as adverse housing conditions or food insecurity​

• Low levels of social support​

• Previous personal psychopathology​

• Family history of bipolar disorder​

• Hormone imbalance​

Depressive Spectrum Disturbance​: Persistent depressive disorder

Time Frame:

• Occurs more days than not for at least two years​

• No more than 2 months without symptoms

Symptoms:

• Poor appetite; insomnia; low energy/fatigue; low self-esteem; poor concentration; feelings of hopelessness; no major depression

Depressive Spectrum Disturbance​: Major Depression

• Can be single major depressive episode or recurrent​

• Can be experienced in varying levels of severity​

• In severe cases may include psychotic features

Time Frame:

• At least five symptoms occurring for at least two weeks

Symptoms:

• Depressed mood for most of the day; markedly diminished interest in activities; significant weight loss/decrease in appetite; insomnia/hypersomnia; psychomotor retardation/agitation; fatigue/energy loss; feeling worthless; diminished concentration; recurrent thoughts of death

Depressive Spectrum Disturbance: Adjustment disorder with depressed mood

• Emotional symptoms in response to an identifiable stressor​

Time Frame:

• Occurring within three months of onset of stressor

Symptoms:

• Marked distress out of proportion to severity/intensity of stressor; significant impairment in functioning

Bipolar Spectrum Disturbances​: Cyclothymia

Time Frame:

• At least two years of periods of numerous hypomanic symptoms and periods of numerous depressive symptoms; no more than two months without symptoms

Symptoms:

• Elevated/expansive or irritable mood; inflated self-esteem; decreased need for sleep; more talkative; racing thoughts; distractibility; increased activity; excessive involvement in pleasurable activities

Bipolar Spectrum Disturbances​: Bipolar I disorder

Time Frame:

Occurrence of one or more manic episode (lasting at least one week) often alternating with major depressive episodes

Symptoms:

Abnormally and persistently elevated/expansive/irritable mood; inflated self-esteem and grandiosity; decreased need for sleep; racing thoughts; distractibility; increased activity; excessive involvement in pleasurable activities; impairment in functioning; psychotic features

Bipolar Spectrum Disturbances​: Bipolar II disorder

Time Frame:

• One or more major depressive episodes accompanied by at least one hypomanic episode

Symptoms:

• See cyclothymia above

Recovery Model and Mood Disturbance​

• Developing long-term collaborative relationship between social worker, client, and family​

• Client understanding of illness and course​

• Identifying factors that contribute to relapse​

• Managing social/environmental stressors​

• Education of family and significant social supports​

• Client decision-making about treatment during periods of stability​

• Plans for managing situations of risk such as risk-taking behaviour (mania) and suicide (depression)​

Psychoeducational Approaches​

• Provision of information, symptoms and treatment and social/family consequences​

• Assistance to recognize prodromal symptoms of relapse​

• Understanding of nature of medication​

• Psychoeducation in addition to medication reduces risk of relapse​

Recovery Oriented Cognitive-Behavioural Therapy​

• People acquire beliefs or cognitive maps of the world from previous experience​

• These beliefs or assumptions become the filter for all subsequent experiences and influence feelings, behaviours, and responses to situations​

• Beliefs or assumptions may be accurate reflections of self and others, or may be distorted (cognitive distortions)​

• Negative beliefs and assumptions can be self-defeating​

• CBT combined with medication more effective than medication alone​

Examples of Cognitive Distortions​

• Catastrophic thinking​

• Filtering

• Overgeneralization

• Polarization

Polarization

Viewing others as all good or all bad​

Overgeneralization

Seeing one setback as a never-ending pattern of defeat​

Filtering

Attending only to negative information and ignoring positives​

Catastrophic thinking​

Small problems are always the beginning of a disaster​

Cognitive-Behavioural Interventions​

• Identify, evaluate and challenge negative assumptions​

• Reframe negative assumptions in a positive or neutral light​

• Modify behavioural responses to situations in order to maximize the possibility of positive outcomes​

• Positive outcomes modify cognitions and influence affect ​

• Mindfulness-Based Cognitive Therapy combines cognitive strategies with meditation​

• Internet-based CBT (iCBT) options for depression with strong support for efficacy in symptom reduction​

Interpersonal Therapy​

• Based on attachment theory​

• Improving interpersonal functioning and working through problems related to loss, change, isolation, or conflict in relationships ​

• Clarification of feelings, expectations, and social roles​

• Developing social competence through problem solving, role playing, and communication analysis

Medications for Depression

• Monoamine Oxidase Inhibitors (MOAI) and Tricyclics​

• Selective Serotonin Reuptake Inhibitors (SSRI)​

• Serotonin Norepinephrine Reuptake Inhibitors (SNRI)​

• Ketamine​

Ketamine​

Experimental use with extreme caution​

Serotonin Norepinephrine Reuptake Inhibitors (SNRI)​

• Mixing the influences of MAOIs and SSRIs​

• Gastric problems, weight gain​

Selective Serotonin Reuptake Inhibitors (SSRI)​

• Selectively increases role of serotonin​

• Long-acting, withdrawal problems, gastric problems​

Monoamine Oxidase Inhibitors (MOAI) and Tricyclics​

• Block breakdown of monoamine (norepinephrine)​

• Dietary restrictions, side effects, problems with overdose​

Other Biological Treatments ​for Mood

• Electroconvulsive therapy (ECT)​

• Transcranial magnetic stimulation (TMS)​

• Light therapy​

• Diet​

Light therapy​

• Primarily for seasonal effects of depression​

• Light therapy combined with antidepressant medication proven to be more effective than drug therapy alone

Transcranial magnetic stimulation (TMS)​

Newer treatment, limited testing ​

Electroconvulsive therapy (ECT)​

Generally last resort​

Medications for Mania and Bipolar Disorder​

• Anti-psychotics for acute manic episodes​

• Anti-depressants for acute depressive episodes​

• Lithium carbonate​

-Long-term use for stabilization​

-Frequent blood tests to monitor lithium levels​

• Anti-convulsants​

-For people who experience rapid cycling​