Psychopathology II: Common Mood Disorders Michael Wilson, PhD University of Illinois Department of Psychology and University of Illinois College of Medicine

A clinical vignette… A 24 year-old male is brought to the hospital by his family. He has only slept 3 hours a night for the last 3 days. The family tells you that he has recently withdrawn large sums of money from his savings account and gone on wild spending sprees. During the interview, he is very talkative and easily distracted. He tells you that he feels “on top of the world.” This patient is most likely to be suffering from: dysthymic disorder major depressive disorder bipolar disorder hypochondriasis cyclothymic disorder

Outline What are unipolar mood disorders? What are bipolar mood disorders? Epidemiology of mood disorders Biology of mood disorders Risk of suicide

Mood disorders Everyone’s mood tends to rise & fall sadness is a normal part of the human condition very happy self-confident end = mania very sad worthless end = depression abnormal if people experience extremes, especially if not consistent with events

Chart: Unipolar Mood Disorder

Chart: Bipolar Mood Disorder

Depressed Mood versus Major Depressive Disorder (MDD) Feeling depressed is different from major depressive disorder!! Major depressive disorder is more than just feeling depressed!! Just feeling sad, even very sad, not sufficient for dx of major depressive disorder Feeling sad is not even necessary for diagnosis of major depressive disorder Severity, intensity, duration matter

Signs and Symptoms of a Major Depressive Episode Sad or empty feelings Anhedonia – loss of interest or pleasure Weight loss/gain or appetite increase/decrease Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or inappropriate guilt Diminished ability to concentrate or indecisiveness Suicidal ideation, plan or attempt Best known by the mnemonic: SIG E CAPS

Criteria for Unipolar Mood Disorders Major depressive disorder Dysthymia At least 1 major depressive episode (lasting at least 2 weeks) Depressive symptoms for at least 2 years No manic or hypomanic episodes

Symptoms of Dysthymia Depressed mood for most of the day on more days than not Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness

Chart: Dysthymia

Clinical Impairment in MDD and Dysthymia Occupationally Socially Other important areas

Exclusion Criteria Not due to a general medical condition (e.g., thyroid condition) Not due to substance use (e.g., alcohol) Not bereavement (it is considered normal to have some symptoms of depression after someone dies)

Types of Mood Disorders Unipolar mood disorders Bipolar mood disorders (previously manic-depression) person experiences only episodes of depression person experiences episodes of mania and in most cases episodes of depression Major depressive disorder Dysthymia Bipolar I disorder Bipolar II disorder Cyclothymia

Symptoms of a Manic Episode Elevated mood Irritable/angry mood 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 or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences

The Difference Between a Manic and a Hypomanic Episode Symptoms Same Duration 1 week 4 days Severity Must interfere with occupational or social functioning Must be noticeable to others, but not severe enough to impair functioning or to require hospitalization

Chart: Bipolar I Disorder

Chart: Bipolar I Disorder

Additional Criteria As with unipolar mood disorders, must be clinical impairment or distress The symptoms cannot be: Due to a medical condition Due to substance use

Epidemiology of Mood Disorders by Gender: Lifetime Prevalence

Gender & Depression Why do almost twice as many women develop depression? women experience more trauma particularly sexual abuse women have more chronic strains poverty, harassment, etc. with equal stressors, women still more likely to develop depression biology, coping style

Prevalence of Major Depressive Disorder by Employment

Prevalence of Major Depressive Disorder by Income

Course and Outcome: Major Depressive Disorder Average age of onset is 23 for males and 25 for females Minimum duration of at least 2 weeks but episodes could last much longer Most people who have major depression will have at least 2 depressive episodes MDD is frequently a chronic and recurrent condition Half recover from their episode of major depression within 6 months. 40% of recovered people relapse within a year

Course and Outcome: Bipolar Disorders Onset is usually between ages 18-20 Average manic episode 2-3 months, bipolar II patients (have hypomania) tend to have shorter and less severe episodes Long-term course Most will have more than one episode Length of intervals between episodes varies and is difficult to predict 40-50% of patients are able to achieve a sustained recovery; rapid cycling patients have a worse prognosis

Etiology: Social Factors and Depression Loss (of significant others, of social role, self-esteem, etc.) plays an important role in onset of depression Social support or lack of social support is a risk factor for depression and suicide

Neurotransmitters & Depression Early theories about lack of serotonin probably overly simplistic Multiple transmitters involved including serotonin, NE, lesser extent dopamine Interaction between neurotransmitters, genes, social stresses is important

More neurotransmitters Serotonin converted from tryptophan in CNS elevation causes improved mood, sleep, but decreased sexual function decrease causes poor sleep, poor impulse control, depression

More neurotransmitters Norepinephrine synthesized by noradrenergic neurons, mostly located in locus ceruleus elevation causes increased mood, anxiety, arousal, learning

More neurotransmitters Dopamine synthesized from tyrosine involved in schizophrenia, psychosis, Parkinson’s, reward system to a lesser extent mood disorders

Antidepressants Serotonin is a particularly important neurotransmitter for mood Selective serotonoin reuptake inhhibitors (SSRIs) are effective Stop reuptake of serotonin at synapses TCAs are older drugs mostly block NE and serotonin also have anticholinergic effects lots of side effects fatal in overdose MAOs block dopamine reuptake lots of side effects!

Depression & Genetics Unipolar depression concordance rates: MZ = .54, DZ = .24 Bipolar disorder concordance rates MZ = .43, DZ = .06 No strong evidence of a single gene responsible for mood disorders

Suicide Depression is a risk factor for suicide 7.5-20 times more likely to commit suicide when have MDD In 1 study*, 2.5 times more likely to commit suicide when in remission *Sokero et al (2005) British Journal of Psychiatry

Suicide Increased risk Reduced risk previous suicidal behavior, family history, severe depression, substance use, poor physical health/perception of poor health, lack of social support Reduced risk suicidal gesture, no family history, mild depression, no substance use, good health, married, strong social support

A clinical vignette… A 24 year-old male is brought to the hospital by his family. He has only slept 3 hours a night for the last 3 days. The family tells you that he has recently withdrawn large sums of money from his savings account and gone on wild spending sprees. During the interview, he is very talkative and easily distracted. He tells you that he feels “on top of the world.” This patient is most likely to be suffering from: dysthymic disorder major depressive disorder bipolar disorder hypochondriasis cyclothymic disorder