Week 5

Major Depressive Disorder

A depressive disorder characterised by a depressed mood lasting more than two weeks and loss of interest in activities.

Major Depressive Disorder - Diagnostic Criteria

1. Depressed mood for more than two weeks.

2. Feeling depressed, sad, empty or hopeless.

3. Loss of interest in previously enjoyed activities (anhedonia).

4. Plus at least four of: weight loss/gain or decreased/increased appetite; loss of energy or excessive fatigue; moto restlessness or slowed movements; diminished concentration, ability to think, or indecisiveness; feelings of worthlessness or guilt; recurrent thoughts of death, suicidal ideation, or a suicide attempt.

DSM-V Specifiers

Extensions to the diagnosis of depression that clarify severity, number of episodes, degree of recovery, and presence of psychotic features.

Persistent Depressive Disorder (Dysthymia)

A chronic depressive disorder lasting at least two years with less severe symptoms than major depression.

Disruptive Mood Dysregulation Disorder

A depressive disorder marked by severe irritability and temper outbursts disproportionate to the situation.

Premenstrual Dysphoric Disorder

A severe form of premenstrual syndrome characterised by significant mood disturbances occurring in the late luteal phase of the menstrual cycle.

Epidemiology of Depression

• Prevalence rates of depression in men (3.1%) and women (5.1%), with women being twice as likely to experience it.

• Median age at onset is approximately 30 years.

• High levels of anxiety and substance abuse are associated with an increased risk of developing depression in young people.

Risk Factors

A history of depression, ongoing family conflict, a history of sexual or physical abuse, residing in a rural area, being of Aboriginal or Torres Strait Islander descent, and having a parent with a psychological disorder.

Recovery and Relapse

• Approximately 50% of individuals with depression recover within six months, but many experience relapse within five years.

• Earlier age of onset, continued experience of some symptoms, multiple prior depressive episodes, ongoing life stressors, and history of depression in family members increases the risk of relapse.

Aetiology of Depression

Factors contributing to depression, including biological, environmental, psychological, and social influences.

Biological Factors

• A family history of mental disorders increases the risk of depression by two to three times.

• Neurotransmitter imbalances are implicated in depression (serotonin, noradrenaline, and dopamine).

• Potential structural or functional abnormalities in the pre-frontal cortex, hippocampus, anterior cingulate cortex, and the amygdala.

Environmental Factors

• Stressful life events (acute: financial disaster; chronic: living with an abusive partner) can act as causal triggers.

• Growing up in a hostile, disruptive, and violent family environment increases the risk of depression.

• Environmental risks usually interact with biological and learnt psychological vulnerabilities to trigger depression.

• It is possible to reduce the impact of stressful life experiences by increasing social support.

Psychological Factors

Include cognitive theories, behavioural theories, and psychoanalytic theories.

Cognitive Theories

• Depressive attributional styles, seeing negative events due to internal, global, and stable factors.

• Beck’s negative cognitive triad, depressed people hold a negative view of the self, the world, and the future, and this view is maintained by cognitive distortions.

Behavioural Theories

• Focus on contingencies associated with depressed and non-depressed behaviours.

• Highlights the role of poor coping skills.

Psychoanalytic Theories

Depression is a form of pathological grief.

Social Factors

• Interpersonal difficulties such as high expressed emotion (relationships involving hostility, high levels of criticism, and over involvement) have been linked to depression.

• Lack of intimate relationships, particularly a risk factor for women.

Protective Factors

Good interpersonal skills, high levels of family cohesion, being connected with one’s community, achievement in a valued pursuit, optimism and low anxiety, openness to experience and effective coping skills.

Beck’s Cognitive Model

A theory suggesting that depression is maintained by automatic negative thoughts and cognitive distortions.

Treatment of Depression

Approaches including pharmacological methods, cognitive behavioral therapy, interpersonal psychotherapy, and psychodynamic therapy.

Relapse Prevention

Strategies to prevent relapse in depression, including medication adherence and coping plans for future triggers.

Prevention of Depression

Interventions focused on teaching coping skills and cognitive strategies, particularly for at-risk populations.

Bipolar Disorder

A spectrum of disorders characterised by episodes of mania and depression, including bipolar I, bipolar II, and cyclothymic disorder.

Diagnosis of Bipolar Disorder

• These disorders all share symptoms of pathologically elevated mood.

• These elevated mood states are referred to as ‘manic’ and hypomanic episodes’.

Manic Episode

A period of elevated mood and increased energy lasting at least one week, with specific symptoms such as grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, heightened activity, and risk taking.

Hypomanic Episode

A milder form of mania lasting at least four days, with less severe symptoms than a manic episode.

Bipolar I Disorder

• Presence of one or more manic episodes.

• Major depression may be present but is not required for diagnosis.

Bipolar II Disorder

• At least one episode of major depression.

• At least one period of hypomania.

• Must not have had a manic episode.

Cyclothymic Disorder

• Symptoms are less severe but more chronic than bipolar I and II.

• Numerous periods of elevated and depressed mood, but not severe enough to meet the criteria for hypomanic, manic, or major depressive episodes.

Under Diagnosis of Bipolar Disorder

Misdiagnosis of bipolar disorder as schizophrenia in men or major depressive disorder in women due to overlapping symptoms.

Over Diagnosis of Bipolar Disorder

Incorrectly diagnosing brief elevated moods as hypomania, often seen in individuals with borderline personality disorder.

Misdiagnosis of Bipolar Disorder

A significant challenge in mental health care, with many individuals initially misdiagnosed with unipolar depression or other disorders.

Causes of Misdiagnosis

• Lack of insight.

• Lack of available information.

• Lack of appropriate assessment tools used.

• The overlap in apparent signs with other disorders.

• The high percentage of comorbidity with other disorders.

Prevalence, Age of Onset, and Course of Bipolar Disorder

• Lifetime prevalence of 1.3%, and a annual prevalence of 0.9%.

• Men and women are equally likely to meet the criteria for bipolar I disorder, women are more likely to meet the criteria for bipolar II disorder.

• Median age of onset is approximately 25 years.

• The majority of time is typically spent in depressive episodes rather than in manic or hypomanic phases.

• High rates of relapse are made worse by poor medication compliance.

Comorbidities of Bipolar Disorder

High rates of anxiety disorders and substance misuse among individuals with bipolar disorder.

Comorbidity with Anxiety Disorders

Nearly one in two individuals with bipolar disorder have a diagnosis of at least one anxiety disorder.

Comorbidity with Substance Misuse

Reported in 39% of people with bipolar disorder.

Comorbidity with Social and Economic Costs

Those with bipolar disorder are almost 5 times more likely to have disrupted relationships.

Comorbidity with Suicide

Suicide rate is nearly 15 times that of the general population.

Aetiology of Bipolar Disorder

Factors contributing to bipolar disorder, including biological heritability and psychological stressors.

Biological Factors

Twin studies suggest a heritability rate of approximately 85% for bipolar disorder.

Psychological Factors

Greater negative beliefs about oneself and the world, temperamental tendencies.

Stressful Life Events

• Diathesis Stress Model: disorders result from interaction between underlying vulnerability and stressful life events.

• Goal Dysregulation Model: mania is the result of excessive goal engagement.

Measures of States and Traits related to Bipolar Disorder

Depression Anxiety Stress Scale; Dysfunctional Attitudes Scale 24; BIS/BAS Scales; Response Style Questionnaire; Internal State Scale.

Treatment of Bipolar Disorder

Includes mood stabilising medications, psychoeducation, cognitive behavioural therapy, interpersonal and social rhythm therapy, and family interventions.