1. Major Depression And Bipolar Disorder
Mood Disorders
Major Depression
And
Bipolar Disorder

2. Mood Disorders
A wide range of behaviors are seen in mood disorders. The three main types of mood disorder are depressive disorders, bipolar disorders, and other mood disorders which are substance-induced or due to general medical conditions.
Facts about Mood Disorders Depressive disorder is relatively common. Bipolar disorders are much less common than depressive disorder. The overall rates of both depressive and bipolar disorders, but not their typical symptoms, seem to be affected by a variety of cultural, economic, and environmental factors.

3. Types of mood disorder Depressive Disorder
Dysthymic disorder: History of depressed mood a majority of the time.
Major depressive disorder: One or more major depressive episodes.
Bipolar Disorders
Bipolar I disorder: One or more manic episodes, and usually one or more major depressive episodes.
Bipolar II disorder: At least one hypomanic episode and one or more major depressive episodes but no manic episode or cyclothymia.
Cyclothymic disorder: Numerous hypomanic episodes and numerous periods of depressive symptoms that do not meet criteria for major depressive episode.

4. Depression
Depression can refer to a symptom or a disorder. The symptom of depressed mood does not necessarily mean a person has a depressive disorder. Although some symptoms of depression occur frequently in people who “have the blues” but are nor clinically depressed, those who do not meet DSM IV criteria experience more symptoms and symptoms are more sever. Depressive disorders are sometime referred to as unipolar disorder to differentiate these types of depression from that found in bipolar disorder. There are several categories of depressive disorder. Patients often describe the symptom of depression as one agonizing emotional pain and sometimes complain about unable to cry, a symptom that resolves as they improve. About two thirds of all depressed patients contemplate suicide, and 10 to 15 percent commit suicide.

5. Structures of mood disorders
A.   Unipolar disorder refers to the experience of either depression or mania, and most individuals with this condition suffer from unipolar depression. Bipolar disorder refers to alternations between depression and mania. Feeling depression and manic at the same time is referred to as a dysphoric manic or mixed episode.
B.  An important feature of major depressive episodes is that they are time limited, lasting 2 weeks to 9 months if left untreated.
 C.  Almost all major depressive episodes remit without treatment. Manic episodes remit without treatment after six months. Thus, it is important to determine the course or temporal patterning of the depressive and manic episodes. Different patterns appear in the DSM-IV-TR under the heading course modifiers for mood disorders.
D. Course modifiers characterize the past mood state and are helpful to predict the future course of the disorder. Understanding the course is related to predicting future occurrences of mood changes and in helping to prevent them.

6. Dysthymic Disorder
     Dysthymic disorder shares many of the symptoms of major depressive, but unlike major depression, the symptoms in dysthymia tend to be milder and remain relatively unchanged over long periods of time, as much as 20 or 30 years. Dysthymic disorder is defined by persistently depressed mood that continues for at least 2 years. During this time, the person cannot be symptom free for more than 2 months at a time. Many eventually experience a major depressive episode at some point.
a.        The mean age of onset for dysthymia is typically in the early 20s (i.e., late onset). The onset of dysthymia before age 21 (i.e., early onset) is associated with (a) greater chronicity, (b) relatively poor prognosis (i.e., response to treatment), and (c) stronger likelihood of the disorder running in the family.
b.       The median duration of dysthymic disorder is approximately 5 years in adults and 4 years in children.
c.        Patients suffering from dysthymia have a higher likelihood of attempting suicide than those suffering from major depressive disorder.

7. DSM-IV-TR Diagnostic Criteria for Dysthymic Disorder
A.depressed mood for mood for most of the day, for more days than not, as indicated either by subjective account or observation by other, for at least 2 years. Note: In adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more0 of the following:
Poor appetite or over eating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
C. During the 2-year period (1 yr. For children or adolescents) of the disturbance, the person has never been without symptoms in criteria A and criteria B for more than 2 months at a time.

8. Cont.DSM-IV-TR Diagnostic Criteria for Dysthymic d/o
D. No major depressive episode has been present during the first 2 years of the disturbance (1 year for children and adolescent_ I.e. the disturbance is not better accounted for by chronic major depressive disorder, in partial remission. Note: there may have been previous major depressive episode provided there was full remission (no significant signs or symptoms for 2 months) before development of the dysthymic disorder.
E. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.

9. Cont. Diagnostic criteria for Dysthymic Disorder
G. The symptoms are not due to the direct physiological effects of a substance (e.g. drug of abuse, a medication) or general medical condition (e.g. hypothyroidism)
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Early Onset: if onset is before age 21 years
Late onset: if onset is age 21 years or older
Specify (for most recent 2 years of dysthymic disorder):
With atypical features

10. Cont. Depression
Almost all depressed patients (97 percent0 complain about reduced energy; they have difficulty finishing tasks, are impaired at school and work, and have less motivation to undertake new projects. About 80 percent of patients complain of trouble sleeping, especially, especially early awakening (I.e. terminal insomnia) and multiple awakenings at night, during which they ruminate about their problems. Many patients have decrease appetite and weight gain and sleep longer than usual. These pt.’s are classified in DSM-IV-TR as having atypical features. Other vegetative symptoms include abnormal menses and decrease interest and performance in sexual activities.

11. Depressed Mood
In every language, we often use the term depression to refer to normal feelings experiences after significant loss, such as the breakup of a relationship or the failure to attain a significant goal. Theses feelings are not classified as a depressive disorder by DSM-VI. Symptoms of grief over the death of a loved one also are not classified as a depression unless they continue for an unusually long period.

12. Vulnerability factors for depression
Genetic makeup, or heredity, is an important risk factor for both major depression and bipolar disorder. Age is also a risk factor. Women are particularly a risk during young adulthood, while for men the risk is highest in early middle age. Gender is also a related risk. Twice as many women as men in the general population report a depressive disorder. Other risk factor are experiencing negative life events and lack of social support, particularly from close relationships. This support may be especially valuable if stressful life events have recently occurred.

13. Major depressive disorder
A major depressive episode is marked by either depressed mood or a loss of interest or pleasure in almost all activities and at least four additional symptoms from the following group: marked weight loss or gain when not dieting; constant sleeping problems; agitated or greatly slowed-down behavior; fatigue; inability to think clearly feelings of worthlessness, and frequent thoughts about death or suicide. These symptoms must last at least 2 weeks and represent a change from the persons usual functioning.

14. Diagnostic criteria for 296
Diagnostic criteria for 296.2x Major Depressive Disorder, Single Episode
presence of a single Major Depressive Episode
The major Depressive Episode is not better accounted for by Schizaoaffective Disorder and is not superimposed on schizoaffective, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
There has never been a manic episode, a mixed episode, or a hypomanic episode. Note: this exclusion does not apply if all of the manic-like, or hypomanic-like episode are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

15. Cont. diagnostic criteria for major depressive disorder, single episode
If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:
Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features
Chronic
With Catatonic Features
With Melancholic Features
With atypical Features
With Postpartum Features
If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder;
In Partial Remission, In Full Remission
With Atypical Features
With Postpartum onset

16. Criteria for Major Depressive Episode
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
(1)
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by other (e.g. appears tearful) Note: in children and adolescent can irritable mood.
(2) Markedly dimishid interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

17. Cont. criteria for major depressive episode
(3) Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase appetite nearly everyday. Note: in children, consider failure to make expected weight gains.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) Fatigue or loss of energy nearly everyday
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-approach or guilt about being sick)
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
((9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

18. Cont. criteria for depressive episode
B. The symptoms do not meet criteria for a Mixed Episode
c. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of Abuse, a medication) or a general medical condition (e.g. hypothyroidism).
E. The symptoms are not better account for by bereavement,I.e. after the loss of loved one, the symptoms persist for longer than 2 months or are characterized by a marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

19. Recurrent Major depressive disorder
When a person who has experience one major depressive episode develops the symptoms again at a later time, the diagnosis is changed to recurrent major depressive disorder.
DSM-IV-TR-Diagnostic criteria, p. 376

20. Causes and Treatment of Depression
Biological factors in Depression- the mechanism for depressed or manic behavior may be the activity of the neurotransmitter systems. An early theory, the monoamine hypothesis focused on the neurotransmitters serotonin and the catecholamines, but other neurotransmitters including GABA and acetylcholine also seem to be involved in depression. The study of the effects of various antidepressant drugs- including MAO inhibitors, tricyclics, and selective serotonin reuptake (SSRIs)-has led to hypothesis about the role of the neurotransmitters in producing behaviors associated with depression. The search for for markers of depression has been an important research strategy. The markers investigated include specific receptor sites in the brain, studied by various scanning devices, and the role of biological rhythms, especially in seasonal affective disorder (SAD).

21. The bipolar disorders
DSM-IV list four bipolar disorders; Bipolar I disorder, Bipolar II disorder, cyclothymic disorder, and a miscellaneous group.
Is an illness involving episodes of mania and depression.
Bipolar I – will experience episodes of mania and usually major depressive episodes as well. bipolar d/o has been found to occur with a higher frequency of creative people such as artist and poets than in the general population. Episodes of bipolar d/o tend to recur. The number of recurrence is greater in those who have a family history that include bipolar disorder.

22. Bipolar disorder I

23. Bipolar disorder
Bipolar II Disorder is variant of bipolar disorder in which there has been no manic episode but at least one hypomanic period as well as a major depressive episode. A hypomanic episode refers to a period of manic behavior that is not extreme enough to greatly impair function. People who experience a hypomanic episode may not see it as pathological, although those around them may be concerned about the erratic behavior they see. For the person affected, the feelings of elation and creativity and the driving energy characteristic of the hypomanic state can be positive forces.
DSM-IV-TR Diagnostic criteria, p.397

24. Manic/hypomanic& mixed episodes
A manic episode is a distinct period of abnormality and persistently elevated, expansive, o irritable mood lasting for at least 1 week, or less if a patient must be hospitalized. A hypomanic episode lasts at least 4 days and is similar to a manic episode except that is not severe enough to cause impairment in social or occupational functioning, and no psychotic features are present. Both mania and hypomania are associated with inflated self-esteem, decrease need for sleep, distractibility, great physical and mental activity, and over involvement in pleasurable behavior