Mood Disorders

1. Mood Disorders

2. Mood Disorders • Depressive Disorders • Major Depressive Disorder • Dysthymic Disorder • Bipolar Disorders • Bipolar I Disorder • Bipolar II Disorder • Cyclothymic Disorder

3. Major Depressive Disorder • aka unipolar depression • lifetime prevalence: • up to 21% in women • 13% in men • typical age of onset: • 20s, but can occur at any time

4. Major Depressive Episode • DSM-IV-TR criteria include • 1 of 2 mood symptoms • at least 5 symptoms total • duration of at least 2 weeks

5. Mood Symptoms of Depression • persistent sad, depressed mood • loss of interest or pleasure in previously enjoyable activities • DSM-IV criteria specify that person must have 1 of above plus 4 additional sx for at least 2 weeks

6. Physical Symptoms of Depression • Sleep disturbance • too much or too little • loss of energy, fatigue • appetite disturbance/weight change • loss of appetite or increase in appetite • changes in activity level • psychomotor retardation or agitation

7. Cognitive Symptoms of Depression • difficulty concentrating, thinking, and making decisions • feelings of worthlessness, guilt, or hopelessness • recurrent thoughts of death or suicide

8. Course of Depression • if untreated, average duration of first episode is 6-9 months • often recur

9. Dysthymic Disorder • Less severe, but more chronic • Chronic “low grade” depression • Depressed mood, plus 2 additional sx • poor appetite or overeating • insomnia or hypersomnia • low energy or fatigue • low self-esteem • poor concentration or difficulty making decisions • feelings of hopelessness

10. Dysthymic Disorder (continued) • Sx must have lasted for at least 2 yrs • Never without symptoms for longer than 2 mos.

11. Double-Depression • dysthymic disorder with episodes of major depression • prognosis more negative

12. Bipolar I Disorder • often called manic depression • typically involves episodes of major depression and mania • lifetime prevalence is 1% for both men and women • typical age of onset is late teens-early 20s

13. Symptoms of Manic Episodes • elevated, expansive, or irritable mood for at least 1 week, plus 3 additional symptoms

14. Symptoms of Manic Episodes • inflated self-esteem/grandiosity • decreased need for sleep (3 hrs.) • unusual talkativeness or pressured speech • flight of ideas/racing thoughts • marked distractibility • increased activity at work, school, or in social situations • excessive involvement in pleasurable activities with potential for painful consequences

15. Course of Bipolar I Disorder • there is great variability in cycle time • 35% of individuals go through only 1 cycle in 5 years • 1% of individuals go through 1 cycle every 3 months • rapid cycling: 4 or more cycles per year

16. Other Bipolar Disorders • Bipolar II • Alternate between hypomanic and major depressive episodes • Cyclothymic Disorder • Alternate between depressive (not MDE) and hypomanic episodes for at least 2 yrs. • Never without symptoms for longer than 2 mos.

17. Hypomanic Episode • Elevated, expansive, or irritable mood for at least 4 days • Symptoms similar to manic episode, except no marked impairment/hospitalization

18. Causes of Mood Disorders: Genetics • twin studies and adoption studies show genetic link for mood disorders • link is stronger for bipolar disorder than unipolar depression

19. Concordance Rates • likelihood that if one member of pair has disease, other member will also have disease • unipolar depression • MZ twins = 36% • DZ twins = 17% • rates are higher for severe depression

20. Concordance Rates (continued) • bipolar disorder • MZ twins = 80% • DZ twins = 16%

21. Causes: Neurotransmitters • depression is associated with low levels of serotonin in relation to norepinephrine and dopamine • primary function of serotonin is to regulate our emotional reactions • when levels of serotonin are low, we are more impulsive and our moods swing more wildly

22. Causes: Neurotransmitters (continued) • medications that treat depression increase the availability of serotonin and/or norepinephrine in the synapse • within a few weeks, this changes postsynaptic receptor sensitivity • change in postsynaptic receptor sensitivity (down-regulation) correlates with symptom improvement

23. Causes: The Endocrine System • depression can be a symptom of some endocrine disorders • hypothyroidism • Cushing’s syndrome • HPA axis • hypothalamus • pituitary gland • adrenal gland • hypothalamus sends signals to pituitary gland, which sends signals to adrenal gland to secrete hormones related to stress response • 50% of depressed individuals show elevated levels of cortisol

24. Causes: Circadian Rhythms • overview • circadian rhythms (sleep-wake, temperature, hunger) are regulated by hypothalamus • exposure to light affects circadian rhythms (suppresses melatonin)

25. Causes: Circadian Rhythms (continued) • interesting findings: • prevalence of seasonal affective disorder is higher in extreme northern and southern lattitudes • depriving depressed patients of sleep can temporarily reduce their depression • extended bouts of insomnia can trigger manic episodes

26. Causes: Circadian Rhythms (continued) • theory • mood disorders are caused by disturbance in circadian rhythms

27. Causes: Stress • general finding: stressful life events are strongly related to the onset of mood disorders • 20-50% of individuals who experience stressful life events become depressed

28. Causes: Stress (continued) • a few caveats: • same stressors that are associated with depression are associated with other disorders • new data indicate that approximately 1/3 of the association between stressful life events and depression is due to the tendency of people who are vulnerable to depression to place themselves in high-risk stressful environments • social support seems to reduce risk for developing depression when exposed to stress

29. Causes: Learned Helplessness • animal research • animals who have been exposed to inescapable aversive events do not make adequate attempts to escape in the future • learned helplessness theory of depression • people become anxious and depressed when they make an attribution that they have no control over the stress in their lives

30. Depressive Attributional Style • attribution • the way in which people assign causes to events in their lives • people who are depressed tend to make attributions that are • Internal • Stable • Global • sense of hopelessness is important

31. Causes: Negative Cognitive Style • tendency to interpret everyday events in a negative way • reflects cognitive errors • all or nothing • seeing things in “black or white” • one order of french fries means I’ve blown my whole diet • overgeneralization • one critical remark on paper means I will fail class • arbitrary inference • selective attention to negative aspects • I assume I’m a terrible teacher because 2 students fell asleep

32. Causes: Negative Cognitive Style (continued) • make negative interpretations about • self • world • future • depressive cognitions emerge from distorted and probably automatic methods of processing information

33. Causes: Cognitive Vulnerability for Depression • 5-year longitudinal study of college students • method • at first assessment: subjects who were not depressed filled out questionnaires to assess cognitive vulnerability to depression • questionnaires: measured dysfunctional attitudes and hopelessness attributions • subjects were assessed every several months for next 5 years for symptoms of depression

34. Causes: Cognitive Vulnerability for Depression (continued) • Results • negative cognitive styles do indicate a vulnerability to later depression • subjects who scored high on measures of cognitive vulnerability were far more likely to experience later depression (17% vs. 1%)

35. Treatment of Depression • Medical • antidepressants • electroconvulsive therapy (ECT) • Psychosocial • cognitive-behavioral therapy • interpersonal therapy

36. Antidepressant Medication • most meds increase levels of serotonin and/or norepinephrine • result in down-regulation of these systems • take 2-8 weeks to work • effective • 65-70% of those on meds improve, vs. 25-30% of those taking placebos • however, 40% will stop taking drugs due to side effects • relapse rate after going off medications is high (50%)

37. Types of Antidepressants • tricyclics • MAO inhibitors • SSRIs • others

38. Tricyclics • block reuptake of norepinephrine and (to a lesser extent) serotonin • examples: • amitriptyline (Elavil) • imipramine (Tofranil) • side effects: • dry mouth, constipation, blurred vision, weight gain, orthostatic hypotension • are likely to be lethal if taken in overdose

39. MAO Inhibitors • block enzyme (monoamine oxidase) which breaks down norepinephrine and serotonin (monoamines) • examples: • phenelzine (Nardil) • tranylcypromine (Parnate) • problem: • dangerously interact with many other drugs (nasal decongestants, SSRIs) and with foods containing tyramine (smoked meats, ages cheeses, beer) • can produce hypertensive crisis

40. SSRIs • selectively inhibit reuptake of serotonin • side effects: • physical agitation, insomnia, gastrointestinal upset, and sexual dysfunction (low desire) • examples • fluoxetine (Prozac) • paroxetine (Paxil) • sertraline (Zoloft) • are less likely to be lethal if taken in overdose

41. Other Antidepressants • buproprion (Wellbutrin) • blocks reuptake of dopamine • venlaxafine (Effexor) and nefazodone (Serzone) • inhibit reuptake of serotonin and norepinephrine

42. Electroconvulsive Therapy • used for depression that doesn’t respond to other treatments • effective • exact mechanism of action is unknown • receive treatments every other day for total of 6-10 treatments • side effects: short-term memory loss

43. Cognitive-Behavioral Therapy • focuses on changing dysfunctional beliefs associated with depression • clients do homework • monitor and log thought processes • engage in hypothesis testing • important to reactivate client • 10-20 weekly sessions • effective

44. Interpersonal Psychotherapy • focuses on resolving problems in client’s existing interpersonal relationships and forming new ones • 4 major areas • dealing with interpersonal role disputes (marital conflict, conflict with friends) • adjusting to the loss of a relationship (death, divorce) • acquiring new relationships (getting married or establishing professional relationships) • identifying and correcting deficits in social skills

45. Interpersonal Psychotherapy (continued) • 15-20 weekly sessions • effective

46. Comparing Treatments • studies compare CBT and IPT to antidepressant meds and other control conditions • results • CBT, IPT, and meds are equally effective • CBT, IPT, and meds are more effective than • placebo conditions • brief psychodynamic treatments • other control conditions • 50-70% of people benefit from treatment to a significant extent, compared to 30% in placebo or control conditions

47. Combined Treatments • Meds work more quickly • Psychosocial treatments • Increase long-range social functioning • Prevent relapse

48. Treatment of Bipolar Disorder • lithium is best known treatment • not sure how it works • side effects • excessive thirst and urination, eventual damage to kidneys and thyroid • blood levels must be carefully monitored • effective • 30-60% respond well initially

49. Treatment of Bipolar Disorder (continued) • other approaches include anticonvulsant medications • example: valproate (Depakote) • psychosocial treatment • family therapy: increase medication compliance, educate family about symptoms, help family develop new coping skills and communication styles • decreases relapse