1. CHAPTER 3 MOOD DISORDERS

2. AIMS AND OBJECTIVES
Provide overview of unipolar and bipolar depression
Describe historical approaches, diagnostic criteria, and epidemiology
Discuss current biopsychosocial approaches to the aetiology and treatment of mood disorders

3. UNIPOLAR DEPRESSION History of Classification
In Ancient Greece, term “melancholia” to describe fear and depression
Kraeplin (1896) used the term manic depressive insanity, which encompassed all mood disorders
Since 1950s, classification system has distinguished between bipolar and unipolar depression
Two types of unipolar depression: major depressive disorder and dysthymia

4. UNIPOLAR DEPRESSION
DSM-IV-TR Diagnosis of Major Depressive Disorder (MDD)
Characterized by the occurrence of > 1 Major Depressive Episodes (MDEs)
Criteria for an MDE
Depressed mood and/or loss of interest (anhedonia) for > 2 weeks
At least 4 of these additional symptoms:
Appetite disturbance
Sleep disturbance
Fatigue
Restlessness or slowed movements
Poor concentration
Feelings of worthlessness or guilt
Thoughts of death or suicide

5. UNIPOLAR DEPRESSION DSM-IV-TR Diagnosis of Dysthymia
Diagnosed when depression is not severe to meet for MDD, but is of longer duration (> 2 years)
Dysthymia + MDD referred to as “double depression”
Other subtypes of depression
Melancholic depression
Psychotic depression
Postnatal depression
Seasonal affective disorder

6. UNIPOLAR DEPRESSION Epidemiology of depression Course Prevalence
In Australia: 3.4% of men, 6.8% of women over 1-year period
Lifetime prevalence ~ 17%
Women 2x as likely to have depression – cause of gender difference
not completely known
Age of onset
As early as 3 years old, median age of onset = 30 years old
Course
Up to 50% with depression recover within 6 months of treatment
10% experience a chronic course
Most who have an MDE will have another episode within 5 years

7. UNIPOLAR DEPRESSION Aetiology of unipolar depression
Biological factors
Genetic factors – family history  2-3x increased risk
Neurotransmitters – serotonin, norepinephrine, dopamine
Neuroendocrine – hyperactivity in HPA axis
Neurophysiological – abnormalities in brain structures, including prefrontal cortex, hippocampus, anterior cingulate, and amygdala
Environmental factors
Stressful life events
Interpersonal difficulties
High level of “expressed emotion” in families of depressed patients

8. UNIPOLAR DEPRESSION Aetiology of unipolar depression
Psychological factors
Cognitive theories
Seligman’s Learned Helplessness Model – depression linked with expectancy of helplessness in face of adverse events
Beck - childhood experiences lead to dysfunctional beliefs, which are triggered by relevant events
Negative Cognitive Triad = Negative view of self, world, and future
Behavioural theories
Influence of adverse events and/or lack of positive reinforcement
Poor coping skills to deal with stressors
Protective factors may reduce risk (e.g., good interpersonal skills, optimism)

9. UNIPOLAR DEPRESSION Treatment Psychological approaches
Medical approaches
Antidepressant medication
Repetitive transcranial magnetic stimulation / Vagus nerve stimulation
Bright light therapy (seasonal affective disorder)
Electroconvulsive therapy (severe depression)
Psychological approaches
Cognitive behaviour therapy
Behavioural activation and problem-solving
Cognitive restructuring for dysfunctional thoughts
Interpersonal psychotherapy
Focus on interpersonal problems related to the depression

10. BIPOLAR DISORDER History Bipolar Diagnoses:
Descriptions of mania date back to ancient Greece
In 19th century, mania and melancholia began to be considered as a single entity
Kraeplin distinguished between “manic depressive insanity” and “dementia praecox”, e.g., schizophrenia
In 1949 Australian researcher John Cade discovered lithium, which revolutionized the treatment of bipolar disorder
Bipolar Diagnoses:
Bipolar I, Bipolar II, and cyclothymia
All 3 of these conditions involve mania or hypomania

11. BIPOLAR DISORDER DSM-IV-TR defines a manic episode:
Elevated, expansive or irritable mood > 1 week, plus 3 of the following:
Inflated self-esteem
Grandiosity
Sleep disturbance
Pressured speech
Flight of ideas
Distractibility
Heightened activity
Excessive risk taking
Must be out of character for the individual
DSM-IV-TR defines a hypomanic episode:
Same symptom profile as mania, except
Symptoms not severe enough to interfere with functioning, necessitate hospitalisation, or involve hallucinations/delusions
DSM-IV-TR also includes the controversial construct of a mixed episode, in which both symptoms of a manic and major depressive episode present for > 1 week

12. BIPOLAR DISORDER Bipolar I Bipolar II Cyclothymia
> 1 manic or mixed episodes (MDE can be present but not necessary)
Bipolar II
>1 MDE plus >1 hypomanic episode
Cyclothymia
Lacks severity to meet for Bipolar I or II
Hypomanic episodes plus depressive symptoms that don’t meet for an MDE
Relationship between schizophrenia and bipolar
Often a mixture between mania and psychotic features
Bipolar can be initially misdiagnosed as schizophrenia

13. BIPOLAR DISORDER Epidemiology
Lifetime prevalence of Bipolar I and II = 3.9%
Men and women equally likely to meet for Bipolar I
Women more likely to meet for Bipolar II
High rates of relapse (73% over 5 years)
Often problems with medication compliance
Problems associated with bipolar disorders
High rates of anxiety disorders and substance abuse among bipolar patients
Substantial social and economic costs
High rate of suicide (15x rate in general population)

14. BIPOLAR DISORDER Aetiology Biological Factors Stressful Events
Strong genetic component
13x increased risk among 1st degree relatives
85% heritability in large twin study
Neurotransmitters play a role
Stressful Events
Diathesis-Stress Model – interaction between underlying vulnerability and stressful life event
Goal Dysregulation Model – excessive goal engagement
Psychological factors
Cognitive disturbances – cause or consequence?
Temperament – perfectionism and high need for social approval

15. BIPOLAR DISORDER Treatment Pharmacological Psychological
Mood stabilisers
lithium, chlorpromazine, valproate, zyprexor, lamictal
Psychological
Psychoeducation for patients and families
Cognitive behaviour therapy
Interpersonal and social rhythm therapy
Family interventions
Relapse prevention

16. SUMMARY Unipolar and Bipolar Depression History Diagnostic criteria
Epidemiology
Aetiology
Biological
Psychological
Environmental
Treatment