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Mood Disorders M Anne Washington Derry (1927) Oil on canvas

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1 Mood Disorders M Anne Washington Derry (1927) Oil on canvas
by Laura Wheeler Waring( )

2 Mood Disorders Depressive Disorders Bipolar Spectrum Disorder
Cyclothymiacs Disorder Mood Disorder duo to GMC Substance induced mood disorder.

3 Depressive Disorders Major Depressive Disorder (single, recurrent)
[Major Depressive Disorder: Postpartum onset]** Dysthymic Disorder Double Depression **Postpartum depression will also be a specifier for bipolar disorder.

4 Major Depressive Disorder: Diagnostic Criteria
5 of following symptoms, must include one of first two, occurred almost every day for two weeks lead to dysfunction Depressed mood Pleasure or interest/ Loss Appetite Sleep disturbance, too much or too little Agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Difficulty concentrating or deciding Recurrent thoughts of death or suicidal thought

5 Depressive Symptoms Mnemonic: “Space Drags”
S leep disturbance P leasure/interest (lack of) A gitation C oncentration E nergy (lack of)/fatigue D epressed mood R etardation movement A ppetite disturbance G uilt, worthless, useless S uicidal thought

6 Mental Status Exam Psychomotor retardation or agitation
Depress mood & affect Non spontaneous speech , Low tone speech Hallucinations, commanding Thought of death, Suicidal thought(60%) & plan & attempt (15%), Negative thought Delusion (appropriate with mood) Cognitive problem : Distractibility ,memory impairment , Concrete thinking

7 Age & Presentation Child hood: Somatic complaint, Agitation, Hallucination, Phobia,… Adolescent : Antisocial behavior ,Truancy Substance abuse , Promiscuity,…. Geriatrics :Apathy ,Distractibility , Psoudodemance.

8 Other Classification Melancholic Atypical Chronic(more than 2 yr)
With seasonal pattern. Post partum onset With Catatonia Double depression Sub clinical depression(Minor depression) With psychotic feature

9 Dysthymic Disorder: Symptoms
Depressed/irritable mood Presence of two of the following: Appetite disturbance Sleep disturbance Low energy/fatigue Poor concentration of difficulties making decision Feelings of hopelessness C. Present for two year period (one year in children and adolescents) D. No evidence of a Major Depressive Epidsode during the first two years (one year for children) E. No manic or hypomanic episode F. No chronic psychotic disorder G. Not related to organic factors

10 Dysthymic Disorder Early Onset: before 21 year old
Late Onset : after 21 year old With or Withought Atypical feature.

11 “Double Depression” Not a diagnosis
Meet diagnostic criteria for both MDD and Dysthymic Disorder

12 Manic Episode: Diagnostic Criteria
A distinct period of abnormally and persistently elevated, expansive, or irritable mood Mood disturbance plus three of the following symptoms (four if the mood is only irritable): Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas, or racing thoughts Distractibility Increase in goal directed activity Excessive involvement in pleasurable activities Marked impairment No psychosis Not organic

13 Hypomania: Diagnostic Criteria
All the criteria of a Manic episode except criterion C (marked impairment)

14 Bipolar Disorder Bipolar I
Alternation of full manic and depressive episodes Average onset is 18 years Tends to be chronic High risk for suicide Bipolar II Alternation of Major Depression with hypomania Average onset is 22 years Tends to be chronic 10% progess to full biploar I disorder

15 Cyclothymia For at least two years (one year for children and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depression During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a time No evidence of MDD or Manic episode during the first two years of disturbance No psychotic disorder No organic cause

16 Mood Disorders: Summary
Depressive Disorders Major Depressive Disorder (single, recurrent) [Major Depressive Disorder: Postpartum onset]** Dysthymic Disorder Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder

17 Mood Disorders: Prevalence Life Time
Major Depression Dysthymia Bipolar I Bipolar II MDD (Postpartum) Prevalence male: 5 – 12 % Female : % 6% 0.8%- 1.6% 0.5% 13%

18 Epidemiology Life time prevalence : High(10-25%)
Gender: Female more than Male(2, times)

19 Differential Diagnosis
Mood Disorder due to GMC (Hypothyroidism) Substance Induced Mood Disorder (Amphetamine , Steroids ,…) Schizophrenia Grief Personality Disorder Adjustment Disorder

20 Prognosis 50% attempt Suicide
Un treated depression get 10 mo or more to recover 75% have recurrence. 5 Episode occurs long life 50% full recovery. 30% partial remission. 20% tend to be Chronic 20%-30% of Dystymic Disorder go to MDD or BMD

21 Major Depressive Disorder: Etiological Theories
Biological (genetic, brain structures, neurotransmitters) Behavior and cognition Emotion Social and cultural factors Developmental factors

22 Major Depression: Genetics
Family studies: Relatives of those with a mood disorder are two to three times more likely to have a mood disorder (usually major depression) Twin studies: If one identical twin has a mood disorder the othe twin is 3 times more likely than a fraternal twin to have a mood disorder (particulrly for bipolar disorder)

23 Major Depression: Genetics
Severe mood disorders may have stronger genetic contribution than less severe disorders Heritability rates are higer for females

24 Major Depression: Neurotransmitters
Low levels of serotonin deregulates the activity of other neurotransmitters such as Dopamine & NE. Imbalance in cortisole & TSH

25 Major Depression: Cognition
Learned helplessness (Seligman) Negative cognitive styles (Beck)

26 Learned Helplessness Attribution of lack of control over stress leads to anxiety and depression Depressive attributional style is internal, stable, and global

27 Negative Cognitive Styles Aaron Beck
Depression is the result of negative interpretations (wearing gray instead of rose colored glasses, e.g. Eyore in Winnie the Pooh) Key Components of Negative Interpretations Maladaptive attitudes (negative schema) Automatic thoughts Cognitive triad Errors in thinking

28 Seligman and Beck Seligman Attributions are: Internal Stable Global
I am inadequate (internal) at everything (global) and I always will be (stable). “Dark glasses about why things are bad” Interpretation (theory) Beck Negative interpretations about: Themselves Immediate world (their place) Future (their place) I am not good at school (self). I hate this campus (world). Things are not going to go well in college (future). “Dark glasses about what is going on” Description

29 Major Depression: Social and Cultural Factors
Stressful life events Social support (marital relationship) (see chart) Gender Culture (see chart)

30 Marital Status and MDD Percentage w/MDD

31 Ethnicity and Prevalence of MDD Percentage by Ethnicity

32 Treatment Major Depression: Overview
Biological Treatments Medication ECT Special note about antidepressants and children Psychological Treatments Cognitive Therapies Interpersonal Psychotherapy (IPT) NIMH Collaborative Treatment Study

33 Biological Treatment Medications
Tricyclic antidepressants Monoamine oxidase (MAO) inhibitors Selective serotonin uptake inhibitors St. John’s Wort ECT (will cover in discussion section)

34 Antidepressant Medication with Children
The effectiveness of antidepressant medication with children is questionable. December 2003 British drug regulators told physicians to stop writing perscriptions for all but one of the newer generation of antideressant drugs to treat children under 18. Benefit did not outweigh the risks (including suicidal thoughts and behavior and agression) Prozac was exempted.

35 Controversy Pro Medication Cost of untreated depression is high
Depression itself is lethal (particularly in teens) Indisputable proof that it works in their own clients Questioned the adequacy of the studies Anti Medication Review of 11 studies of effects of medication in children revealed that the risks outweigh the benefits Evidence based practice is guided by the results of research not clinician’s opinions

36 Psychological Treatments
Cognitive-Behavioral Treatment Interpersonal Therapy

37 Which treatment is best?

38 Depression Collaborative Research Program Many Controversial Issues
Treatment Groups Cognitive Therapy Interpersonal Psychotherapy Medication Imiprimine Placebo & Clinical Management Outcome Measures Depressive Symptoms Overall symptomotology and life functioning Functioning in treatment specific domains Procedures 16 weeks of treatment Extensive Assessment: T Results Follow-up-18 months Equivalent success in three active treatments Only 20 to 30% of recovered patients were still well Patients in IPT report more satisfaction with treatment IPT and CBT patients more likely to report that treatment affected capacity to establish and maintain relationships and to understand source of their depression Results: Post-Treatment Equivalent success in three active treatments over placebo Medication was faster IPT better than CBT for more severely depressed patients Particular treatments effected change in expected domains Many Controversial Issues

39 Childhood Onset Depression
Special Topic 1 Childhood Onset Depression

40 Childhood Onset Depression: Historical Aspects
Initial View Psychoanalytic: developmentally children could not experience depression Sadness results from loss of valued object/person Sadness results in hostility and aggression Depression is result of inward hostility Children lack superego development to direct aggression toward self

41 Childhood Onset Depression: Historical Aspects
Initial View: Clinical findings of Rene Spitz

42 Childhood Onset Depression: Historical Aspects
Early View: Masked Depression Later rejected: Difficult to verify Depressive symptoms were evident

43 Current Childhood Onset Depressive Disorders
Adjustment Disorder with Depressed Mood Dysthymic Disorder Major Depression Bipolar Disorder

44 Adjustment Disorder with Depressed Mood
Short-term Emotional or behavioral problems Reaction to identified stressor

45 Special Topic 2 Suicide

46 Suicide 8th leading cause of death in the U.S.
Overwhelmingly white phenomena Suicide rates also quite high in Native American Rate of suicide is increasing in adolescents and elderly Males are more likely to commit suicide Females are more likely to attempt suicide (except China)

47 Suicide: A Sociological Typology Emile Durkeim
Formalized or altruistic suicide Egoistic suicide Anomic suicides Fatalistic suicide Sanctioned suicide Disintegration of social support Major disruption Loss of control of one’s destiny (mass suicide’s)

48 5 Myths and Facts About Suicide
People who talk about killing themselves rarely commit suicide. Fact: Most people who commit suicide have given some verbal clues or warnings of their intentions

49 5 Myths and Facts About Suicide
The suicidal person wants to die and feels there is no turning back. Fact: Suicidal people are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems.

50 5 Myths and Facts About Suicide
If you ask someone about their suicidal intentions, you will only encourage them to kill themselves. Fact: The opposite is true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment.

51 5 Myths and Facts About Suicide
All suicidal people are deeply depressed. Fact: Although depression is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.

52 5 Myths and Facts About Suicide
Suicidal people rarely seek medical attention. Fact: 75% of suicidal individuals will visit a physician within the month before they kill themselves.

53 Sociodemographic Risk Factors
Male > 60 years Widowed or Divorced White or Native American Living alone (social isolation) Unemployed (financial difficulties) Recent adverse life events Chronic Illness

54 Clinical Risk Factors Previous Attempts
Clinical depression or schizophrenia Substance Abuse Feelings of hopelessness Severe anxiety, particularly with depression Severe loss of interest in usual activities Impaired thought process Impulsivity

55 Assessing Risk and Planning Intervention
Level Specific Plan Risk Factors Severity Intent Interven. Low No Few None Safety Plan Mod. Vague Plan/low lethal Increased Severe lethal plan Remove Lethal Items Extreme Specific lethal plan Intent to die Hospitalize

56 Clinical Considerations of Suicide Assessment
For those who are reluctant to assess suicide: Asking questions may feel intrusive but not asking has dangerous consequences A calm and genuinely concerned approach is effective

57 Suicide:Treatment Problem-solving Cognitive behavioral therapy
Coping skills Stress reduction

58 Postpartum Depression Special Topic # 3
See separate Power Point presentation

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