Diagnosing and Treating Mood Disorders: The Science and Ethics

1. Diagnosing and Treating Mood Disorders: The Science and Ethics Chris Trimble, Leo Huizar, Fredah Kabbech, Megan Sieveke, Brandon Butler

2. Mood Disorders

3. Can refer to either: A mood: a pervasive and sustained emotional response A clinical syndrome: a combination of emotional, cognitive and behavioral symptoms Depression

4. How To Distinguish Depression From Normal Sadness • The mood change is pervasive across situations and persistent over time • The mood change may occur in the absence of any precipitating events • The depressed mood is accompanied by impaired ability to function in usual social and occupational roles • The change in mood is accompanied by a cluster of additional signs and symptoms • The nature or quality of the mood change may be different from that associated with normal sadness

5. Emotional Cognitive Somatic Behavioral Four Types of Symptoms Associated With Mood Disorders

6. Emotional Symptoms • Depressed or dysphoric mood is the most common and obvious symptom of depression • People who are depressed describe themselves as feeling utterly gloomy, dejected and despondent • Manic patients experience euphoric like symptoms

7. Cognitive Symptoms • Involve changes in the way people think about themselves and their surroundings • Depressed people may have trouble concentrating and are easily distracted • Preoccupation with guilt and worthlessness • Manic patients report sped up thoughts and ideas

8. Somatic Symptoms • Related to basic physiological or bodily functions • Include fatigue, aches and pains, and serious changes in appetite or sleeping patterns

9. Behavioral Symptoms • Changes in the things that people do and the rate at which they do them • Psychomotor retardation often accompanies the onset of depression • Manic patients show energetic, provocative and flirtatious behavior

10. Diagnosing Mood Disorders • Defined in terms of episodes • discrete periods of time in which the person’s behavior is dominated by either a depressed or manic mood

11. Major Depressive Episode • Five or more of the following symptoms must have been present during the same two week period and represent a change from previous functioning • At least one of the symptoms is either • Depressed mood • Loss of interest or pleasure

12. Depressed mood most of the day, nearly every day Diminished pleasure in all, or almost all activities Significant weight loss (without dieting) or weight gain Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Diminished ability to think or concentrate Recurrent thoughts of death or suicidal ideation Major Depressive Episode Symptoms

13. Manic Episode • A distinct period of abnormally and persistently elevated, or expansive mood, lasting at least one week • During the period of mood disturbance, three of more of the following symptoms have persisted and have been present to a significant degree

14. Inflated self esteem or grandiosity Decreased need for sleep More talkative than usual Flight of ideas Distractibility (drawn to unimportant stimuli) Increase in goal directed activity Excessive involvement in pleasurable activities that have a high potential for painful consequences Manic Episode Symptoms

15. Mood Disorders • Two primary types: • Unipolar mood disorder: the person experiences only episodes of depression • Bipolar mood disorder: the person experiences episodes of mania as well as depression

16. Types of Mood Disorders and Frequency

17. Unipolar Mood Disorders Major Depressive Disorder Dysthymic Disorder Bipolar Mood Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Subtypes Types of Mood Disorders

18. One or more major depressive episodes No manic or unequivocal hypomanic episodes Lifetime prevalence of 15% Major Depressive Disorder 15% suicide mortality VA 1991 Study Major Depressive Disorder mortality 38.7% 13% no psychiatric monitoring Major Depressive Disorder

19. Major Depressive Disorder • Course is variable • Some having episodes years apart, clusters of episodes, and some with frequent episodes throughout life • Only about 20% have chronic episodes • After the first episode, 50%- 60% chance of a second , and a 5%-10% chance of a manic episode (i.e. developing bipolar I disorder) • After second episode, 70% chance of a third • After third episode, 90% chance of a fourth • The greater number of previous episodes is an important risk factor for recurrence

20. Major Depressive Disorder • By definition, Major Depressive Disorder cannot be due to: • Physical illness, alcohol, medication, or street drug use. • Normal bereavement. • Bipolar Disorder • 7Mood-incongruent psychosis (e.g., Schizoaffective Disorder, Schizophrenia, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified).

21. Major Depressive DisorderCo-occurring Disorders • Substance Abuse • Anxiety • 80 to 90% of individuals with Major Depressive Disorder also have anxiety symptoms (e.g., anxiety, obsessive preoccupations, panic attacks, phobias, and excessive health concerns). • Cancer, COPD (Chronic Obstructive Pulmonary Disease), Pain, eating disorders • Causation: • Meds: steroids • Diseases: hypothyroidism

22. Dysthymic Disorder • Depressed mood for at least two years • Never without at least two of the following symptoms for more than two months • Poor appetite or overeating, insomnia or hypersomnia, low energy, low self esteem, poor concentration, feelings of hopelessness

23. Dysthymic Disorder • No major depressive episode during the first two years • Lifetime risk of 3%

24. Bipolar I Disorder • One or more manic episodes • Lifetime risk of 1%

25. These positron emission tomography scans of the brain of a person with bipolar disorder show the individual shifting from depression, top row, to mania, middle row, and back to depression, bottom row, over the course of 10 days.

26. Bipolar II Disorder • One or more major depressive episodes • At least one hypomanic episode • A hypomanic episode is a less severe version of a manic episode. • No manic episodes

27. Subtypes of Mood Disorders • Melancholia: describes a particularly severe type of depression • Psychotic features: when hallucinations or delusions were present during the most recent episode • Rapid cycling: the person experiences at least 4 episodes within a 12 month period

28. Postpartum Onset: when episodes begin within 4 weeks after childbirth Seasonal affective disorder: when the onset of episodes is regularly associated with changes in seasons Subtypes of Mood Disorders

29. Prevalence of Mood Disorders • Depression accounts for more than 10 percent of all disabilities in the US • Younger generations are experiencing higher rates of depression, and those who become depressed are doing so at an earlier age • Depression affects 13-14 million people each year

30. Prevalence of Mood Disorders • Ratio of unipolar to bipolar is at least 5:1 • Lifetime prevalence of all mood disorders is 8%, ranked third behind substance abuse disorders and anxiety disorders

31. Gender Differences • Women are two or three times more vulnerable to depression than men • Sex hormones, stressful life events, childhood adversity, etc • May be more likely to seek treatment • May be more likely to be labeled as depressed • No differences seen in bipolar disorders

32. Children Statistics • Up to 2.5% of children in the US suffer from depression • Up to 8.3% of adolescents in the US suffer from depression • Girls entering puberty are twice as likely to experience depression as boys

33. Causes of Mood Disorders

34. Types of Causes • Environmental Factors • Psychological Factors • Biological Factors

35. Environmental Factors:Stress • Levels of stress may vary from person to person. • Depressive episodes can make a person more vulnerable to further episodes, so small amounts of stress can activate depression • “Learner Helplessness”- after experiencing chronic or repeated stressful events, people can learn to feel helpless

36. Environmental Factors: Substance Abuse • Depression that is a result of drug abuse, medication, or toxin exposure • Associated with use and withdrawl from: alcohol, amphetamine, cocaine, hallucinogens, inhalants, opioids, phencyclidine, sedaitves, hypnotics and anxiolytics • Exposure or habitual use of chemicals can alter brain structure and function resulting in depression

37. Environmental Factors:Childhood Difficulties • Depression can develop in children who have experienced a traumatic event including but not limited to: • Death of family member or friend • Natural disaster • Divorce • Loss of parent’s job, home, etc... • Many of these children are emotionally damaged or lack emotional development and often have difficulties adjusting • Traumatic Event may affect the development of the Limibic System

38. Depression In Disease • Estimated 1/3 people with chronic disease have depression. • Alzheimer’s • Boston Study • 14% had history of depression • HIV • 1/3 estimated to have depression

39. Continued… • The rate for depression occurring with medical illness*: • Heart attack: 40-65% • Coronary artery disease (without heart attack): 18-20% • Parkinson's disease: 40% • Multiple sclerosis: 40% • Stroke: 10-27% • Cancer: 25% • Diabetes: 25% *Reviewed by the doctors at The Cleveland Clinic Department of Psychiatry and Psychology.

40. Psychological Factors • Cognitive Vulnerability • People responding differently to the same negative experience involving loss, failure and disappointment

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43. Biological Factors • Neurotransmitters and Neurons • The signal enters the neuron through the dendrite and proceeds through the cell body to the axon where it is switched from a electric signal to a chemical one • Theses chemical signals are called neurotransmitters • Neurotransmitters can fit into many receptors, but receptor sites can only receive specific transmitters • Upon release the transmitter is broken down by mono amine oxidase (MAO) or its taken back in by the neuron that released it, called “reuptake”

44. Biological Factors • Of the 30 or so known neurotransmitters, depression effects Serotonin, Norepinephrine, and Dopamine • Depression has been linked to both low and elevated Norepinephrine concentrations.

45. Biological Factors: Serotonin • The permissive hypothesis of serotonin function postulates that the deficit in central serotonergic neurotransmission permits the expression of bipolar disorder but is not sufficient to cause it. • According to this theory, both the manic and the depressive phases of bipolar illness are characterized by low central serotonin function but differ in high versus low norepinephrine activity.

46. Biological Factors:Norepinephrine • The catecholamine hypothesis of affective disorders proposes that some forms of depression are associated with a deficiency of catecholamine activity (particularly norepinephrine) at functionally important andrengeric receptor sites in the brain, whereas mania is associated with a relative excess.

47. Biological Factors:Dopamine • Evidence is substantial that enhanced dopamine activity may play a primary role in psychotic depression.

48. Biological Factors: Hormones • About one half of all depressed persons have a high level of the hormone cortisol in their blood • A person with a depressive mood disorder may not have their hypothalamus regulating the cortisol production in the adrenal gland correctly • Normal cortisol levels peak at 8:00a.m. and 4:00p.m. for non depressed person, while a person with depression may have the hormone released at a constant level

49. Biological Factors: Genetics • There is a 1.5 to 3% greater chance for a person to develop a depressive disorder if a parent or sibling has it as well • 50% of those with bipolar disorder have a parent with history of clinical depression • 25% of children of a parent who is bipolar develop a depressive disorder • 50-75% of children of two parents with bipolar disorder develop a depressive disorder

50. Biological Factors: Twin Studies • If one twin develops depression there is a 76% chance that the other twin will develop a disorder as well • When raised apart the percentage is 67% • Because this number is not closer to 100%, there is indication that other factors are also responsible • Fraternal twins have a 19% chance of developing a depressive disorder if the other develops one