CLP CH7

An Overview of Depression and Mania

• Mood disorders* (terms marked with an asterisk are key terms) involve gross deviations in mood

• Composed of different types of mood “episodes”

• Periods of depressed or elevated mood lasting days or weeks, including:

  • Major depressive episode*

  • Mania*

  • Hypomanic episode*

Major Depressive Episode ( > 2 weeks)

• Extremely depressed mood and/or loss of pleasure (anhedonia)

• Lasts most of the day, nearly every day, for at least two weeks

• At least four additional physical or cognitive symptoms:

• Indecisiveness, feelings of worthlessness, fatigue, appetite change, restlessness or feeling slowed down, sleep disturbance

Manic Episode ( > 1 week)

• Elevated, expansive mood for at least one week

• Examples of symptoms:

  • Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors

  • Impairment in normal functioning

Other Types of Mood Episodes

• Hypomanic episode

  • Shorter, less severe version of manic episodes

• Mixed features

  • Mood episode with symptoms reflecting both valences (manic and depressive)

DSM-5 (Unipolar) Depressive Disorders

• Major depressive disorder

  • Persistent depressive disorder* ( dysthymia* )

  • New to DSM-5:

    • Premenstrual dysphoric disorder

    • Disruptive mood dysregulation disorder

Major Depressive Disorder: An Overview

Clinical features

One or more major depressive episodes separated by periods of remission

Recurrent* episodes more common than single episodes

Specifiers include peripartum onset and seasonal pattern (seasonal affective disorder)

The Structure of Mood Disorders

Mixed features: Condition in which the individual experiences both elation and depression or anxiety at the same time. Also known as dysphoric manic episode or mixed manic episode.

Depressive Disorders

If two or more major depressive episodes occurred and were separated by at least 2 months during which the individual was not depressed, the major depressive disorder is noted as being recurrent.

Persistent Depressive Disorder: An Overview ( > 2 Years )

At least two years of depressive symptoms

Depressed mood most of the day on more than 50% of days

No more than two months symptom free

Double depression: An individual experiences both persistent depressive disorder and episodes of major depression.

Fewer symptoms

Catatonia: A state marked by a lack of movement, response, or communication, often associated with severe mental disorders such as schizophrenia.

Epidemiology of Depressive Disorders

Risk increases in adolescence and young adulthood, decreases in middle adulthood, increases again in old age (U-shaped pattern)

Depressive episodes are variable in length

Usually last several months untreated, but may last several years

Additional Defining Criteria

Some individuals in the midst of a major depressive (or manic) episode may experience psychotic symptoms, specifically hallucinations (seeing or hearing things that aren’t there) and delusions.

Other Depressive Disorders

Premenstrual dysphoric disorder: Significant depressive symptoms occurring prior to menses during the majority of cycles, leading to distress or impairment

Disruptive mood dysregulation disorder: Severe temper outbursts occurring frequently, against a backdrop of angry or irritable mood

Diagnosed only in children 6 to 18

Another name for those experiencing postpartum depression is the "baby blues," which refers to the emotional fluctuations and mood changes that many women experience after giving birth.

DSM-5 Bipolar Disorders

Bipolar I disorder: Alternations between major depressive episodes and manic episodes

Bipolar II disorder: Alternations between major depressive episodes and hypomanic episodes

Cyclothymic disorder: Alternations between less severe depressive and hypomanic periods.

Individuals with cyclothymic disorder tend to be in one mood state or the other for years with relatively few periods of neutral (or euthymic) mood. This pattern must last for at least 2 years (1 year for children and adolescents) to meet criteria for the disorder.

Seasonal Affective Disorder (SAD): A mood disorder involving a cycling of episodes corresponding to the seasons of the year, typically with depression occurring during the winter.

Increased production of melatonin may cause depression in vulnerable people.

An individual with bipolar disorder who experiences at least four manic or depressive episodes within a year is considered to have a rapid-cycling pattern, which appears to be a severe variety of bipolar disorder that does not respond well to standard treatments

Prevalence of Mood Disorders

Worldwide lifetime prevalence of major depressive disorder is 16%

6% have experienced major depression in last year

Sex differences:

Women are twice as likely to have major depression

Bipolar disorders approximately equally affect men and women

Similar prevalence among U.S. subcultures, but experience of symptoms may vary

Some cultures more likely to express depression as somatic concern

Higher prevalence among Native Americans: Four times the rate of the general population

Life Span Developmental Influences on Mood Disorders

Young children typically don’t show classic mania or bipolar symptoms

Mood disorder may be misdiagnosed as ADHD

Children are being diagnosed with bipolar disorders at increasingly high rates

Depression in elderly between 14% and 42%

Co-occurrence with anxiety disorders

Less gender imbalance after 65 years of age

Causes of Mood Disorders: Familial and Genetic Influences

Family studies

Risk is higher if relative has a mood disorder

Relatives of bipolar probands are more likely to have unipolar depression

Twin studies

Concordance rates are high in identical twins

Two to three times more likely to present with mood disorders than a fraternal twin of a depressed co-twin

Severe mood disorders have a strong genetic contribution

Heritability rates are higher for females compared to males

Some genetic factors confer risk for both anxiety and depression

Causes of Mood Disorders: Neurobiological Influences

Serotonin: Regulates norepinephrine and dopamine, mood disorders are related to low levels of serotonin

Permissive hypothesis: Low serotonin “permits” other neurotransmitters to vary more widely, increasing vulnerability to depression

The endocrine system: Elevated cortisol, Decreases neurogenesis in the hippocampus

Sleep disturbance

Hallmark of most mood disorders

Depressed patients have quicker and more intense REM sleep

Psychological Dimensions (1 of 3)

Stressful life events

Stress is strongly related to mood disorders

Context of life events matters

Gene-environment correlation: People who are vulnerable to depression might be more likely to enter situations that will lead to stress

The learned helplessness theory* of depression: Lack of perceived control over life events leads to decreased attempts to improve own situation

Psychological Dimensions (2 of 3)

Attributional style of people with depression: Internal attributions, Negative outcomes are one’s own fault, Stable attributions

Believing future negative outcomes will be one’s fault

Global attribution

Believing negative events will disrupt many life activities

All three domains contribute to a sense of hopelessness

Psychological Dimensions (3 of 3)

Negative coping styles

Depressed persons engage in cognitive errors

Tendency to interpret life events negatively

Arbitrary inference – overemphasize the negative aspects of a mixed situation

Overgeneralization – negatives apply to all situations

Cognitive errors and the depressive cognitive triad*

Think negatively about oneself

Think negatively about the world

Think negatively about the future

Social and Cultural Dimensions

Marital relations

Marital dissatisfaction is strongly related to depression

This relation is particularly strong in males

Social support

Extent of social support is related to depression

Lack of social support predicts late onset depression

Substantial social support predicts recovery from depression

Gender Differences in Mood Disorders

Women account for seven out of ten cases of major depressive disorder.

Possible explanations for gender disparity relate differences in socialization and differences in disadvantage including the experience of discrimination, poverty, sexual harassment, and abuse.

Antidepressant Medication

Classes of antidepressants:

• Selective serotonin reuptake inhibitors

  • temporarily increases levels of serotonin at receptor sites

  • first choice of drug treatment

• Tricyclic antidepressants

• Monoamine oxidase inhibitors

  • a class of antidepressants that work by preventing the breakdown of norepinephrine and serotonin, thereby increasing their availability in the brain.

• Mixed reuptake inhibitors: serotonin/norepinephrine reuptake inhibitors

Approximately equally effective

About 50% of patients benefit

Only 25% achieve normal functioning

Dr. Aaron Beck is globally recognized as the father of Cognitive Behavior Therapy (CBT) and is one of the world's leading researchers in psychopathology.

Medication for Bipolar Disorder

Lithium carbonate

Treatment of choice for bipolar disorder

Considered a mood stabilizer* because it treats depressive and manic symptoms

Toxic in large amounts

Dose must be carefully monitored

Effective for 50% of patients

Anticonvulsants and calcium channel blockers may be used if lithium not effective

70% relapse over a five year period

Other Medical Treatments

• Electroconvulsive therapy* effective for severe medication-resistant depression

  • Brief electrical current applied to the brain leading to seizure

  • Side effects:

    • Headaches, memory loss that may be permanent

• Transcranial magnetic stimulation uses magnets to generate a precise localized electromagnetic pulse

  • Few side effects; occasional headaches

  • Less effective than ECT for medication-resistant depression

Suicide: Facts and Statistics (1 of 2)

• Tenth leading cause of death in USA

  • Underreported; actual rate may be two to three times higher

• Most common among white and Native Americans

• Recent increases in death by suicide among adolescents

• Rates have also increased in people 65 and older

Suicide: Facts and Statistics (2 of 2)

• Gender differences

  • Men complete more suicides than women

  • Women attempt suicide more often than men

  • Disparity is due to men using more lethal methods

  • Exception: Suicide more common among women in China

    • May reflect cultural acceptability; suicide is seen as an honorable solution to problems

Indices of Suicidal Behavior

• Suicidal ideation* : serious thoughts about suicide

• Suicidal plans* : a detailed method for killing oneself

• Suicidal attempts* that are nonfatal

Suicide Contagion

• Suicide contagion* :

  • Some research indicates that a person is more likely kill themselves after hearing about someone else committing suicide

• Media accounts may worsen the problem by

  • Sensationalizing or romanticizing suicide

  • Describing lethal methods of killing oneself

A disorder characterized more by impulsivity than depression is borderline personality disorder (see Chapter 12). Individuals with this disorder, known for making manipulative and impulsive suicidal gestures without necessarily wanting to destroy themselves, sometimes kill themselves by mistake in as many as 10% of the cases.