Anne Washington Derry (1927) Oil on canvas by Laura Wheeler Waring(1887 - 1948)

1. Mood Disorders M Anne Washington Derry (1927) Oil on canvas by Laura Wheeler Waring(1887 - 1948)

2. Mood Disorders Outline of Lectures • Description of Mood Disorders • Etiological Theories Major Depression III. Treatment Major Depression

3. Mood Disorders • Depressive Disorders • Mania

4. Depressive Disorders • Major Depressive Disorder (single, recurrent) • [Major Depressive Disorder: Postpartum onset]** • Dysthymic Disorder • Double Depression **Postpartum depression will be presented separately in a single lecture. Can also be a specifier for bipolar disorder.

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

6. Depressive Symptoms Mnemonic:“Space Drags” S leep disturbance Pleasure/interest (lack of) Agitation Concentration Energy (lack of)/fatigue Depressed mood R etardation movement Appetite disturbance Guilt, worthless, useless S uicidal thought

7. MDD, Single episode Absence of mania or hypomania MDD, Recurrent 2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood Major Depression

8. 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

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

10. Bipolar Disorders • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

11. 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

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

13. 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 Bipolar Disorder

14. 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

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

16. Disorders Major Depression Dysthymia Bipolar I Biploar II MDD (Postpartum) Prevalence 4.9% 3.2% 0.8% 0.5 13% Mood Disorders: Prevalence

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

18. 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)

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

20. Major Depression: Neurotransmitters • Low levels of serotonin deregulates the activity of other neurotransmitters • Permissive hypothesis

21. Major Depression: Endorcrine System • Elevated cortisol

22. Major Depression: Cognition • Learned helplessness (Seligman) • Negative cognitive styles (Beck)

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

24. Negative Cognitive StylesAaron 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

25. 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 Seligman and Beck

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

27. Marital Status and MDDPercentage w/MDD

28. Ethnicity and Prevalence of MDDPercentage by Ethnicity

29. Major Depression: Developmental Factors • Children • Teens • Elderly

30. 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

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

32. 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.

33. 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 Controversy

34. Psychological Treatments • Cognitive-Behavioral Treatment • Interpersonal Therapy

35. Which treatment is best?

36. Depression Collaborative Research Program 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

37. Special Topic 1 Childhood Onset Depression

38. 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

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

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

41. Current Childhood Onset Depressive Disorders • Adjustment Disorder with Depressed Mood • Dysthymic Disorder • Major Depression • Bipolar Disorder

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

43. Special Topic 2 Suicide

44. 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)

45. 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) Suicide: A Sociological TypologyEmile Durkeim

46. Myth #1: 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 5 Myths and Facts About Suicide

47. Myth #2: 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. 5 Myths and Facts About Suicide

48. Myth # 3: 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. 5 Myths and Facts About Suicide

49. Myth # 4: 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. 5 Myths and Facts About Suicide

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