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