2An Overview of Depression and Mania Mood Disorders“Depressive disorders”“Affective disorders”“Depressive neuroses”Gross deviations in moodDepressionMania
3An Overview of Depression Major depressive episodeExtreme depression2 weeksCognitive symptomsPhysical dysfunctionAnhedoniaDuration - 4 to 9 months, untreatedCognitive symptoms such as worthlessness and indecisivenessDysfunction is physical and includes sleep, appetite, energy levelsAnhedonia loss of pleasure or interest in thingsTechnology Tip: Check out the site of the National Foundation for Depressive Illness, Inc., for more information on depression. Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: A Self-Rating Depression Scale.
4Exaggerated elation, joy, euphoria 1 week, or less Cognitive symptoms An Overview of ManiaManic episodeExaggerated elation, joy, euphoria1 week, or lessCognitive symptomsPhysical dysfunctionDuration – 3 to 6 months, untreatedHypomanic episodeCognitive symptoms flight of ideas, grandiosityDysfunction is physical and includes decreased sleep, hyperactive, rapid speechhypomanic (hypo means below) episode is a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning
5Structure of Mood Disorders Unipolar disordersDepression or mania aloneTypically depressionBipolar disordersDepression and maniaMixed episodesTechnology Tip: Check out The National Institute of Mental Health site devoted to depression and bipolar disorder.
6Structure of Mood Disorders Diagnostic considerationsAccompanying symptomsOverlap between disordersSeverityCourseRecurrentAlternatingSeasonalSymptom overlap includes weight changes, irritability, cognitive distortions, sleep changes
7Depressive Disorders: An Overview Major Depressive DisorderNo mania/hypomaniaSingle episodeRareRecurrent4 episodes (lifetime)Duration – 4 to 5 monthsSingle episode - as many as 85% of single-episode cases later have a second episodeRecurrent – two or more episodes separated by two months or more during which the individual was not depressedTeaching Tip: The movies Ordinary People and Leaving Las Vegas provide depictions of depression.Technology Tip: The Major Depressive Disorder Internet Mental Health provides this informative web page; information on other disorders is provided as well.
8Major Depressive Disorder OnsetLow until early teensMean age = 30Figure 7.1 – Cross cultural data on the onset of major depressive disorderTechnology Tip: Dr. Ivan’s Depression Central offers links to several sites on mood disorders, including sites for books, videos, research, diagnosis, and treatment.
9Depressive Disorders: An Overview Dysthymic DisorderMilder symptoms2+ yearsChronicPersistentChronic - can persist unchanged yearsPersistent- cannot be symptom free for more than 2 months at a timeTechnology Tip: Dysthymia Internet Mental Health provides this informative web page; information on other disorders are provided as well.
10Stronger familial component Median duration = 5 years Dysthymic DisorderOnset = early 20’sEarly onset = before 21Greater chronicityPoor prognosisStronger familial componentMedian duration = 5 yearsDepends on comorbidityChronic - can persist unchanged yearsPersistent- cannot be symptom free for more than 2 months at a time
11Dysthymic DisorderFigure 7.2 HDRS scores of dysthymic disorder patients
12Depressive Disorders: An Overview Double DepressionMajor depressive episodes and dysthymic disorderDysthymia firstSevere psychopathologyPoor courseHigh recurrence ratesRecurrence is high if dysthymia is untreatedTeaching Tip: Have students participate in the following Instructor Resource Manual Video Activity: Abnormal Psychology, Inside/Out, Vol. 1. After reviewing the nature of depressive disorders, present the video segment depicting Barbara, but do not let on about her diagnosis. Ask students to see if they can arrive at a diagnosis for Barbara. The correct answer is Unipolar Depression, without Psychosis.
13Depression frequently follows loss 62% after death Grief and DepressionDepression frequently follows loss62% after deathPathological or Complicated GriefSeverity of symptomsDysfunctionPersistence of symptomsTechnology Tip: The following articles offer interesting information on grief and depression:Technology Tip: Interesting information and links about bereavement and grief:
14Bipolar I Disorder: An Overview Alternating major depressive and manic episodesSingle manic episodeRecurrentSymptom free for 2 monthsTeaching Tip: Have students participate in the following Instructor Resource Manual Activity: Bipolar Disorder ScreeningTechnology Tip: Bipolar Disorder Internet Mental Health provides this informative web page; information on other disorders are provided as well.Teaching Tip: Have students read the complete book or excerpts from Kay Jamison’s book, An Unquiet Mind, which offers excellent insight into bipolar disorder.
15Bipolar I Disorder: An Overview StatisticsOnset = age 18ChildhoodChronicSuicideSuicide attempts 17% for BP I, 24% for BPII, 12% unipolar depression, completed suicide is 4x higher than depressionTechnology Tip: Visit the following NIMH site for more information on bipolar disorders and suicide:
16Alternating major depressive and hypomanic episodes Bipolar II DisorderAlternating major depressive and hypomanic episodesStatisticsOnset = age 19 to 22ChildhoodChronic10 to 13% of cases progress to full Bipolar I disorderTechnology Tip: The University of Maryland Medical Center site offers more information on the distinction between bipolar I and II:
17Alternating manic and depressive episodes Less severe Persists longer Cyclothymic DisorderAlternating manic and depressive episodesLess severePersists longerChronic symptomsAdults = 2+ yearschildren and adolescents= 1+ yearTechnology Tip: Cyclothymia Internet Mental Health provides this informative web page; information on other disorders are provided as well.
18Cyclothymic Disorder Statistics Onset = age 12 or 14 Chronic Lifelong Female>MaleRisks for Bipolar I/IIHigh risk for developing Bipolar I or II disorder
19Additional Defining Criteria Symptom SpecifiersAtypicalMelancholicChronicCatatonicPsychoticMood congruent/ incongruentPostpartumAtypical – Oversleep, overeat, weight gain, anxietyMelancholic – Severe depressive and somatic symptomsChronic – Major depression only, lasting 2 yearsCatatonic – Absence of movement, very seriousPsychotic – Mood congruent hallucinations/delusionsMood incongruent features possible, but rarePostpartum – Manic or depressive episodes after childbirth
20Additional Defining Criteria Figure 7.3 Mood disorders and specifiers for the most recent episode of the disorder
21Additional Defining Criteria Course SpecifiersLongitudinal courseRapid cycling patternSeasonal patternDepression vs. maniaMelatoninPhototherapyCBTTechnology Tip: Visit the Mayo Clinic site for more information on SAD:Longitudinal course specifiers are used to address whether a person has had a past episode of depression or mania and whether the person recovered fully from past episodes. For example, one should determine whether dysthymia preceded a major depressive episode or whether cyclothymic disorder preceded bipolar disorder. Both scenarios tend to decrease chances of recovery and increase length of treatment.Rapid cycling pattern applies only to bipolar I and II disorders. Rapid cycling pattern is used when a person has at least 4 manic or depressive episodes within a period of 1 year. Rapid cycling is a more severe form of bipolar disorder that does not respond well to treatment, and appears to be associated with higher rates of suicide. Alternative drug treatments (e.g., anticonvulsants, mood stabilizers) are typically utilized with individuals meeting criteria for this specifier.Seasonal pattern applies to bipolar disorders and recurrent major depression and is used to indicate whether episodes occur during certain seasons, usually wintertime. Those with winter depressions display excessive sleep and weight gain. Seasonal affective disorder may be related to circadian and seasonal changes in the increased production of melatonin (i.e., a hormone secreted by the pineal gland). Phototherapy is a recommended effective treatment for this condition.
22Prevalence of Mood Disorders Table 7.3 Prevalence of mood disorders
23Prevalence of Mood Disorders Children and AdolescentsSimilar to adultsSymptom presentationsPrevalenceEarly childhoodAdolescenceMisdiagnosisADHDConduct disorderTechnology Tip: For more information, visit the NIMH site:Children fundamentally similar to adults; no childhood mood disorders in the DSM-IV-TR. Children less than 9 years of age show more irritability and emotional swings rather than classic manic states, and are often mistaken as hyperactive.Depressive disorder occurs less often in children than adults but that this difference closes somewhat during adolescence, where depression becomes more frequent compared to adults. Bipolar disorder is rare in childhood, but rises substantially in adolescence and so does suicide.
24Prevalence of Mood Disorders ElderlyPrevalence may depend on settingSymptom profileFemale : Male = 1:1Diagnostic difficultyComorbiditiesTechnology Tip: For more information, visit the following sites: ;Elderly - 18% to 20% of nursing home residents, likely to be chronic.Symptoms- sleep problems, hypochondriasis, and agitation.Diagnostic difficulty- medical illnesses and symptoms of dementia; menopause for womenPrevalence - MDD is the same or slightly lower as in the general population.Comorbidities- GAD and panic disorder (33%), alcohol (33%),Gender - imbalance in depression disappears after age 65.
25Prevalence of Mood Disorders Across CulturesSimilar prevalence among US subculturesExceptionsPhysical or somatic symptomsComparabilityExceptions – Native American village depression was 1.5 to 4x higher than general population; SES and stressSymptoms- weakness, tirednessComparability – constructs, statements, wording
26Prevalence of Mood Disorders Among the creativeHigher prevalenceMelancholiaManiaGender differencesJamison study- 20% or more prevalence rate of bipolar for recent American poetsGender – female poets, more than other artists and politicians, perhaps due to independent and sometimes rebellious qualities in the context of gender roles.
27Overlap of Anxiety and Depression More alike than differentAlmost all depressed persons are anxiousNot all anxious persons are depressedNegative affectCore symptoms of depressionAnhedoniaSlowingNegative cognitionsTechnology Tip: The following Reuters article discusses the overlap between depression and anxiety:Technology Tip: The following Psychology Today article discusses the overlap between depression and anxiety:
28Causes of Mood Disorders : Biological Familial and Genetic InfluencesFamily StudiesAdoption StudiesTwin StudiesBipolarUnipolarHigher concordance with higher severityHigher heritability for femalesFamily Studies- rate is 2-3x higher in relatives of probandsAdoption StudiesTwin Studies – identical twins are 2-3x more likely than fraternalBipolar: identical 66.7%, fraternal 18.9%;Unipolar: identical 45.6%, fraternal 20.2%Females 40% vs 20% for males
29Causes of Mood Disorders : Biological Figure 7.4 Co-occurrences of types of mood disorders in twins
30Depression and Anxiety: The Same Genes? Shared genetic vulnerabilityHigh familial heritabilitySame genetic factorsGeneral predispositionExcept mania?Technology Tip: Visit the site for the Johns Hopkins Department of Psychiatry and Behavioral Sciences Genetics of Mood Disorders research website:
31Causes of Mood Disorders : Biological Neurotransmitter SystemsSerotonin - depressionThe “permissive” hypothesisDopamineNorepinephrineDopamine - maniaTechnology Tip: Visit the following sites for more information on the neurobiology of depression and the “permissive hypothesis”:
32Causes of Mood Disorders : Biological Endocrine System“Stress hypothesis”Overactive HPA axisNeurohormonesElevated cortisolSuppressed hippocampal neurogenesisDexamethasone suppression test (DST)Neurohormones – unclear, but likely relationship to antecedent neurotransmittersDST- Dexamethasone depresses cortisol secretion; 50% with mood disorders show less suppressionSuppressed hippocampal neurogenesis – via long term production of stress hormones
33Causes of Mood Disorders : Biological Sleep and Circadian RhythmsREM sleepReduced latencyIncreased intensityDecreased slow wave sleepSleep deprivation effectsSleep deprivation during the second half of the night causes temporary mood improvementsTechnology Tip: Check out the following article for more information on using sleep deprivation to treat depression:
34Causes of Mood Disorders : Biological Brain Wave ActivityIndicator of vulnerability?Greater right side anterior activationLess alpha wave activityThis pattern is seen in individuals who are no longer depressed and in adolescent offspring of depressed mothers- may be a indicator of a biological vulnerability
35Causes of Mood Disorders : Psychological Stressful life eventsContextMeaningTimingEffects of stressPoorer treatment responseDelayed remissionTrigger for episode or relapseBipolar- episodes triggered by lack of sleep or jetlag.
36Causes of Mood Disorders : Stress Reciprocal-gene environment modelStress triggers depressionDepressed individuals create or seek out stressful situationsInteraction with vulnerabilityGeneticPsychologicalReciprocal-gene environment model – genetic endowment may increase the probability of experiencing a stressful life event
37Causes of Mood Disorders : Psychological Learned Helplessness (Seligman)Lack of perceived controlDepressive Attributional StyleInternalStableGlobalAlso characterizes anxietyInternal - Negative outcomes are one’s own faultStable- Believing future negative outcomes will be one’s faultGlobal- Believing negative events disrupt many life activities
38Causes of Mood Disorders : Psychological Sense of hopelessnessLack of perceived controlWill not regain controlPessimismBefore or after?Those with anxiety do not give up and become hopeless about regaining control
39Causes of Mood Disorders : Psychological Negative Cognitive StylesCognitive Theory of Depression (Beck)Cognitive errors in depressionNegative interpretationsTypes of Cognitive ErrorsArbitrary inferenceOvergeneralizationArbitrary inference – Overemphasize the negativeOvergeneralization – Negatives apply to all situationsTechnology Tip: Visit Dr. Beck’s homepage for more information and links:
40Causes of Mood Disorders : Psychological Beck’s Depressive Cognitive TriadFigure 7.6 Beck’s cognitive triad for depression.
41Causes of Mood Disorders : Psychological Cognitive Theory of Depression (Beck)Negative schemasAutomatic thoughtsTreatment implicationsCorrecting the errorsTechnology Tip: The Beck Institute website offers more information on research and treatment related to CBT:
42Causes of Mood Disorders : Psychological Cognitive Vulnerability for DepressionPessimistic explanatory styleNegative cognitionsHopelessness attributionsInteractions with:Biological vulnerabilitiesStressful life events
43Mood Disorders: Social and Cultural Dimensions Marriage and Interpersonal RelationshipsRelationship disruption precedes depressionStrongest effects for malesMartial conflict vs. marital supportGender differences in causal directionConflict and support- both may be high, low, or absent, or any combinationGender and cause – depression causes men to withdraw or otherwise disrupt the relationship, for women relationship problems cause depression
44Mood Disorders: Social and Cultural Dimensions Mood Disorders in WomenPrevalence: Females > malesTrue for all mood disordersExcept bipolarFigure 7.7 Lifetime international rate per 100 people for major depression.
45Mood Disorders: Social and Cultural Dimensions Mood Disorders in WomenGender rolesPerceptions of uncontrollabilitySocializationAccess to resourcesGender differences in: Feelings of mastery, control, and being valuedTechnology Tip: Facts about Women and Depression An NIMH web page, containing many facts regarding women and mental health.
46Mood Disorders: Social and Cultural Dimensions Social SupportRelated to depressionLack of supportpredicts late onset depressionSubstantial supportpredicts recovery for depression (not mania)
47Integrative Theory of Mood Disorders Shared biological vulnerabilityPsychological vulnerabilityExposure to StressSocial and interpersonal relationshipsShared Biological Vulnerability - overactive neurobiological response to stress, similar to anxietyPsychological vulnerability – pessimism, sense of uncontrollability, helplessness and hopelessnessExposure to Stress - activates hormones, neurotransmitter systems, certain genes, affects circadian rhythmsSocial and interpersonal relationships- act as moderators
48Integrative Theory of Mood Disorders Figure 7.8 An integrative model of mood disorders.
49Treatment of Mood Disorders Changing the chemistry of the brainMedicationsECTPsychological treatment
50Treatment : Antidepressant Medications Tricyclics (Tofranil, Elavil)Frequently used for severe depressionBlock reuptake/down regulateNorepinephrineSerotonin2 to 8 weeks to workMany negative side effectsLethalitySide effects - blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain, and sexual dysfunction. Because of the side effects, about 40% of patients stop taking the drugs.Efficacy -tricyclics alleviate depression in 50% of cases to as high as 65% to 70% of cases.Technology Tip: Info on pharmacological treatments for depression can be found at:
51Treatment : Antidepressant Medications Monoamine Oxidase (MAO) InhibitorsBlock MAOHigher efficacyFewer side effectsInteractionsFoodsMedicinesSelective MAO-IsMonoamine Oxidase (MAO) - Enzyme that breaks down serotonin/norepinephrineEfficacy- slightly more effective than tricyclics and have fewer side effects.However, ingestion of tyramine foods (e.g., cheese, red wine, beer) or cold medications with the drug can lead to severe hypertensive episodes and occasionally death. New MAO inhibitors (not yet widely available) are more selective, short acting, and do not interact negatively with tyramine. MAO inhibitors are usually prescribed only when tricyclics prove to be ineffective.
52Treatment : Antidepressant Medications Selective Serotonin Reuptake InhibitorsFluoxetine (Prozac)First treatment choiceBlock presynaptic reuptakeNo unique risksSuicide or violenceMany negative side effectsSide effects - physical agitation, sexual dysfunction or low desire, insomnia, and gastrointestinal upset.
53Treatment : Antidepressant Medications Other medicationsVenlafaxineSimilar to tricyclicsNefazodoneSimilar to SSRIsSt. John’s WortQuestionable efficacyTechnology Tip: For more information on St. John’s Wort and depression, visit the following sites:nccam.nih.gov/health/stjohnswort
54Treatment : Antidepressant Medications Other issuesEfficacy in special populationsChildrenElderlyPreventing relapseMaintaining benefitsChildren- cardiac problemsElderly- increased side effect profilesTechnology Tip: The following article from the APA Monitor discusses treatment efficacy in the elderly
55Treatment of Mood Disorders: Lithium Common saltPrimary treatment for bipolar disordersUnsure of mechanism of actionNarrow therapeutic windowToo little –ineffectiveToo much – toxic, lethalMechanism- may work on dopamine, norepinephrine, and/or the endocrine system; electrolytesTechnology Tip: Visit the following site for more information on the treatment of bipolar disorders:
56Treatment of Mood Disorders: Antimanics Other antimania drugsCarbamazepineValproateMost frequently prescribedHigh efficacyExcept suicide!Fewer side effects
57Treatment of Mood Disorders: ECT Electroconvulsive TherapyBrief electrical currentTemporary seizures6 to 10 treatmentsHigh efficacySevere depressionFew side effectsRelapse is commonSide effects - Short-Term Memory Loss, confusion, both are transientEfficacy -50% not responding to meds will get betterTechnology Tip: The site has some interesting (and controversial) information from a former patient who underwent the procedure.
58Treatment of Mood Disorders: TMS Transcranial magnetic stimulationLocalized electromagnetic pulseFewer side effectsEfficacy is likely goodMore studies neededSide effects - headachesEfficacy -50% not responding to meds will get betterTechnology Tip: The following sites offer links and more information on TMS:groups.csail.mit.edu/vision/medical-vision/surgery/tms.html
59Psychological Treatment of Mood Disorders Cognitive TherapyIdentify errors in thinkingCorrect cognitive errorsSubstitute more adaptive thoughtsCorrect negative cognitive schemasBehavioral ActivationIncreased positive eventsExerciseTechnology Tip: The Beck Institute website offers more information on research and treatment related to CBT:
60Psychological Treatment of Mood Disorders Interpersonal PsychotherapyAddress interpersonal issues in relationshipsRole disputesLossNew relationshipsSocial skill deficitsAddress interpersonal role disputes, adjustments to losing a relationship, acquisition of new relationships, and social skills deficits.Technology Tip: The International Society for Interpersonal Psychotherapy site provides information about IPT and its clinical and research applications:Technology Tip: Also see the University of Michigan site on IPT:
61Psychological Treatment of Mood Disorders CBT and IPT OutcomesComparable to medicationsMore effective than:PlaceboBrief psychodynamic treatmentTechnology Tip: The following article from the APA Monitor discusses treatment efficacy compared to medications:
62Combined Treatment of Mood Disorders Possible benefits above individual treatments48% benefit from meds or CBT73% benefit from combinedMore research is needed
63Prevention of Mood Disorders Universal programsSelected interventionsIndicated interventionsPreventing relapseUniversal programs – applied to everyoneSelected interventions – those at increased risk (divorce, family alcoholism)Indicated interventions –those showing early signs of depressionFigure 7.9 Hollon et al. (2006) Annual Review of Psychology
64Psychological Treatment of Bipolar Disorders Management of interpersonal problemsIncrease medication complianceInterpersonal and Social Rhythm TherapyFamily-focused treatmentInterpersonal and Social Rhythm Therapy -Regulates circadian rhythms, Sleep, eating cycles, Decreased relapseTechnology Tip: The following article offers more information on ISRT:
65Suicide: Statistics Population specific Caucasians Native Americans Increasing ratesAdolescentsElderlyGender differencesIndicesAttemptsIdeationsMales are more likely to commit suicideFemales are more likely to attempt suicideTechnology Tip: Visit the NIH Suicide Prevention site for more information on suicide statistics and prevention:Teaching Tip: The movies The Hours, Dead Poet’s Society, and The Virgin Suicides provide illustrations of suicide and the effects on others
66Suicide: Past Conceptions Types of suicide (Durkheim)AltruisticEgoisticAnomicFatalisticFormalized or altruistic suicide is socially or familially sanctioned (e.g., to avoid dishonor to self or family).Egoistic suicide, which may be common in the elderly, is suicide caused by disintegration of social support.Anomic suicides occur following some major disruption in one's life (e.g., sudden loss of a high prestige job)..Fatalistic suicides related to a loss of control over one's destiny (e.g., mass suicide of Heaven’s Gate cult).
67Past suicidal behavior Shameful/humiliating stressor Suicide: Risk FactorsFamily historyLow serotonin levelsPreexisting disorderAlcoholPast suicidal behaviorShameful/humiliating stressorSuicide publicity and media coverageTechnology Tip: The Suicide Information and Education Center site has more information on risk and resourcesTechnology Tip: For more information, visit the American Association of Suicidology site:Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Suicide Questionnaire
68Suicide: Risk FactorsFigure 7.14 Threshold model for suicidal behavior
69Importance of assessment Previous attempts Recent events Ideation Plan Suicide: TreatmentImportance of assessmentPrevious attemptsRecent eventsIdeationPlanMeansAccessTechnology Tip: For more information, visit :suicide.htmlTechnology Tip: The Suicide Awareness/Voices of Education site includes links and other information on suicide:
70Problem solving therapy CBT Suicide: TreatmentNo-suicide contractHospitalizationComplete or partialProblem solving therapyCBTTeaching Tip: Have students participate in the following Instructor Resource Manual Activity: Suicide PreventionDiscussion Tip: Lead a discussion on the strengths and weakness of a “no suicide” contract. How would it be different if it were verbal, written, witnessed, or worded by the individual versus the therapist? What are the legal ramifications for the therapist?
71Future DirectionsInteraction between biology and psychologyBiological challenge studiesInduced depressionSerotonin and pessimism