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Chapter Seven
Depressive and Bipolar Disorders
Assessing Mood Symptoms
• Mood: prolonged emotional state
• Pervasive, life-altering disturbances that can
impair functioning across life-span
• Differ from temporary emotional reactions:
– Affect every part of person’s life
– Continue for weeks or months
– Often occur for no apparent reason
– Extreme reactions that are out-of-proportion to
life circumstances
Assessing Mood Symptoms (cont’d.)
Figure 7-1 Depressive and Bipolar Disorders Across the Life Span Biological,
psychological, social, and sociocultural factors increase vulnerability to depressive and
bipolar disorders during different life stages.
Source: C.B. Nemeroff. Recent Findings in the Pathophysiology of Depression. Focus, January 1,
2008; 6(1): 3-14. Reprinted with permission from Focus, copyright © 2008. American Psychiatric
Association.
Assessing Mood Symptoms (cont’d.)
• Depressive disorders:
– Individuals often experience one extreme mood
• Bipolar disorders:
– Individuals often experience both depression and
mania
Assessing Mood Symptoms (cont’d.)
Symptoms of Depression
• Depression:
– Mood state characterized by intense sadness or
despair, feelings of worthlessness, and withdrawal
from others
– Core feature of many depressive disorders and
also commonly seen in bipolar disorders
Symptoms of Depression (cont’d.)
• Mood symptoms:
– Depressed mood, with feelings of sadness,
emptiness, hopelessness, worthlessness, or low
self-esteem
– Little enthusiasm for things they once enjoyed
– Irritability and feelings of anxiety
Symptoms of Depression (cont’d.)
• Cognitive symptoms:
– Pessimistic, self-critical beliefs
– Thoughts of suicide
– Interferes with memory, concentration, and
decision-making
– Rumination:
• Continually thinking about certain topics or reviewing
events that have occurred
• Often involves irrational and unjustified beliefs
Symptoms of Depression (cont’d.)
• Behavioral symptoms:
– Fatigue, social withdrawal, and reduced
motivation
– Daily activities may seem overwhelming
– Slow speech and short responses
– Some seem agitated and restless
– Lack of concern for personal cleanliness
Symptoms of Depression (cont’d.)
• Physiological symptoms:
– Appetite and weight changes
– Sleep disturbance
– Unexplained aches and pain
– Aversion to sexual activity
Symptoms of Mania
• Hypomania:
– A milder form of mania involving increased levels
of activity and goal-directed behaviors combined
with elevated, expansive, or irritable mood
– Distractibility, impulsivity, and risk taking
– Does not cause impairment in social or
occupational functioning
– Can progress into a full manic episode
Symptoms of Mania (cont’d.)
• Mania:
– Very exaggerated activity and emotions including
euphoria, excessive excitement or irritability,
diminished need for sleep and resultant
impairment in social or occupational functioning
– Psychotic symptoms may be present
Symptoms of Mania (cont’d.)
• Mood symptoms:
– Emotionally unstable with mood changes ranging
from extreme elation to intense rage
– Elevated mood
– Increased energy and enthusiasm
– Inappropriate use of humor and poor judgment
– Grandiosity
• An overvaluation of one’s significance or importance
– Extreme irritability, hostility, and agitation
Symptoms of Mania (cont’d.)
• Cognitive symptoms:
– Disorientation, lack of focus and attention, and
poor judgment
– Lack of insight regarding inappropriateness of
behavior
– Pressured speech
• Rapid, frenzied, or loud, disjointed communication
– Flight of ideas
• Rapidly changing or disjointed thoughts
Symptoms of Mania (cont’d.)
• Behavioral symptoms:
– Uninhibited
– Impulsivity and difficulty delaying gratification
– Failure to evaluate consequences of decisions
– Rapid and incoherent speech
– Psychotic symptoms may be present
• Paranoia, hallucinations, and delusions
– Individuals are often hospitalized after becoming
dangerous to themselves or to others
Symptoms of Mania (cont’d.)
• Physiological symptoms:
– Decreased need for sleep
– High levels or arousal
– Increased sex drive
– Weight loss due to high energy expenditure
Evaluating Mood Symptoms
• Questions asked for diagnostic clarification:
– Mild, moderate, or severe symptoms
– Frequency and duration of episodes
– Seasonal changes in mood
– Patterns of alcohol or other substance use
– Age of onset
• Postpartum depression
– Presence of anxiety or suicidality
– Mixed features
Depressive Disorders
• Group of related disorders characterized by
depressive symptoms
• Include:
– Major depressive disorder
– Dysthymic disorder
– Premenstrual dysphoric disorder
• Depressive disorders under study:
– Mixed anxiety/depressive disorder
– Seasonal affective disorder
Diagnosis and Classification of
Depressive Disorders
• For diagnosis, hypomanic or manic episodes
have never been present
• Diagnosis is made based on severity of and
chronicity of depressive symptoms
Diagnosis and Classification of
Depressive Disorders (cont’d.)
• Major depressive disorder:
– Diagnosis requires that a major depressive
episode impair functioning for most of the day,
nearly every day for at least two full weeks
– Major depressive episode
• Period involving severe depressive symptoms that have
impaired functioning for at least two weeks
Diagnosis and Classification of
Depressive Disorders (cont’d.)
Major Depressive Disorder (Barbara), Part I and II Interview with Barbara, who suffers
from major depressive disorder
Diagnosis and Classification of
Depressive Disorders (cont’d.)
• Dysthymic disorder (chronic depression):
– Symptoms are present most of the day for more
days than not during a two-year period with no
more than two months symptom-free
– Ongoing presence of at least two symptoms:
•
•
•
•
•
•
Feelings of hopelessness
Low self-esteem
Poor appetite or overeating
Low energy or fatigue
Difficulty concentrating or making decisions
Sleep difficulties
Diagnosis and Classification of
Depressive Disorders (cont’d.)
• Mixed anxiety/depression:
– Symptoms of depression are accompanied by
anxious distress
– Anxious distress
• Symptoms of motor tension, difficulty relaxing,
pervasive worries, or feelings that something
catastrophic will occur
– Neither anxiety nor depression is predominant
– Associated with longer depressive episodes and a
higher risk of suicide
Diagnosis and Classification of
Depressive Disorders (cont’d.)
• Seasonal affective disorder (SAD):
– Severe depression that occurs with a seasonal
pattern associated with decreasing light
– Symptoms typically begin in the fall or winter and
remit during spring or summer
– Two seasonal episodes of severe depression and a
pattern of seasonal depressive episodes
– Symptoms include:
• Low energy, social withdrawal, increased need for
sleep, and carbohydrate craving
Diagnosis and Classification of
Depressive Disorders (cont’d.)
Seasonal Changes & Affect Randy Nelson works with hamsters to study how changes
in daylight affect mood, affect depression, specifically. He hopes to eventually extend this
research to people, identifying ties to SADS in humans. While that stage is a long way
off, Dr. Nelson does measure anxiety, depression, and other emotional states in hamsters
(using established clinical behavioral criteria for calling them anxious).
Diagnosis and Classification of
Depressive Disorders (cont’d.)
• Premenstrual dysphoric disorder (PMDD):
– Symptoms of depression, irritability, and tension
that appear the week before menstruation and
remit soon after menstruation begins
– Premenstrual symptoms must be present:
• Symptoms include significant depressed mood, mood
swings, anger, anxiety, tension, irritability, increased
interpersonal conflict, and others
– Produces significant distress and interferes with
social and occupational functioning
Prevalence of Depressive Disorders
• One of most common psychiatric disorders
• Leading cause of worldwide disability
• About $50 billion spent annually in U.S. on
health care services and lost workdays
• 15 million Americans suffer in a year
Prevalence of Depressive Disorders
(cont’d.)
Figure 7-2 12-Month and Lifetime Prevalence of Depressive and Bipolar Disorders
Source: Based on Hasin, Goodwin, et al. (2005); R.C. Kessler, Berglund, Demier, Jin, Koretz, et
al. (2003); Merikangas, Akiskal, et al. (2007).
Prevalence of Depressive Disorders
(cont’d.)
• Increased risk for women, Native American,
middle-aged, widowed, separated or divorced,
and low income
• Recurrence rate high
• Incomplete remission is common
• Misdiagnosis leads to ineffective treatment
leading to greater impairment
Etiology of Depressive Disorders
Figure 7-3 Multipath Model of Depression The dimensions interact with one another
and combine in different ways to result in depression.
Etiology of Depressive Disorders
• Biological dimension:
– Role of heredity:
• Depression tends to run in families, and same types of
disorder found among family members
– Gender differences in heritability
• Genetics seem to increase anxiety symptoms in some
people with depression
• Serotonin transporter gene (5-HTT)
Etiology of Depressive Disorders
(cont’d.)
• Biological dimension:
– Circadian rhythm disturbances in depression:
• Insomnia can both cause and worsen depression
• Sleep disturbances, including increased REM sleep,
strongly linked to depression
– Cortisol, stress, and depression :
• High blood levels of cortisol linked to depression, but
influence is unclear
• Role of early life traumas or stressors
• Damage to hippocampus
• Depletion of serotonin due to chronic stress
Etiology of Depressive Disorders
(cont’d.)
• Biological dimension:
– Neurotransmitters and depressive disorders:
• Abnormalities in availability of neurotransmitters
• Norepinephrine, serotonin, and dopamine
– Neuroanatomy and depression:
• Decreased brain activity
• Abnormalities in brain structures that affect motivation,
appetite, sleep, energy level, circadian rhythm, and
response to rewarding and aversive stimuli
• Difficult to isolate one single cause
Etiology of Depressive Disorders
(cont’d.)
• Psychological dimension:
– Behavioral explanations:
• Depression occurs when insufficient social
reinforcement is received
• Variables that can increase or decrease access to
positive reinforcement (Lewinsohn, et al.):
–
–
–
–
Number of potentially reinforcing events and activities
Availability of reinforcements in the environment
Behavior of the individual
Stressful events can also produce depression by disrupting
predictable behavioral patterns
Etiology of Depressive Disorders
(cont’d.)
• Psychological dimension:
– Cognitive explanations:
• The way people think causes depression
• Depressed individuals have negative thoughts and
errors in thinking that result in pessimism, negative
self-views, and feelings of hopelessness
Etiology of Depressive Disorders
(cont’d.)
• Psychological dimension:
– Beck’s cognitive theory:
• Depression is a disturbance in thinking, not mood
• The way people interpret experiences affects mood
• Depressed individuals have pessimistic outlooks
regarding present experiences and future expectations
• Exaggeration of personal limitations and minimization
of accomplishments, achievements, and capabilities
• Rumination and co-rumination increases risk
Etiology of Depressive Disorders
(cont’d.)
• Psychological dimension:
– Learned helplessness:
• Learned belief that one is helpless and unable to affect
outcomes in one’s life
– Attributional style
• People who feel helpless make erroneous assumptions
about why events occur
• Personal versus external factors
• Unchangeable versus temporary situation
• Global versus specific thinking
Etiology of Depressive Disorders
(cont’d.)
• Social dimension:
– Maltreatment during childhood, loss of a parent,
and stressful life events have a moderate effect
– Parental depression
– Severe acute stress is often linked with depression
• Stress and depression are bidirectional
• Stress may activate a genetic predisposition for
depression
– Targeted rejection has strong link
– Timing of negative life events
Etiology of Depressive Disorders
(cont’d.)
• Sociocultural dimension:
– Culture, ethnicity, and depression:
• Cultural differences in symptoms, treatment, doctorpatient interactions, and likelihood of outcomes
– Depression is experienced differently
• Perceived discrimination based on gender, race or
ethnicity, or sexual orientation
– Immunizing people against depression:
• Various interventions can prevent or reduce symptoms
Etiology of Depressive Disorders
(cont’d.)
• Sociocultural dimension:
– Gender and depressive disorders:
• Universally. depression is far more common among
women than among men
–
–
–
–
–
Women may be more likely to seek treatment
Women may be more willing to report
Diagnostic bias
Depression in men may take other forms
Environmental, sociocultural, and biological factors interact,
influencing gender differences
– Variations in hormone levels
– Traditional gender roles
Treatment for Depression
• Biomedical treatments:
– Medication (antidepressants):
• Tricyclics, MAOIs, and SNRIs: block re-absorption of
norepinephrine and serotonin
• SSRIs: block reuptake of serotonin
• Atypical antidepressants: affect other
neurotransmitters, including dopamine
• Symptom-suppressive, not curative
• Concerns: publication bias, placebo effectiveness, and
increases in suicidality
Treatment for Depression (cont’d.)
ABC Video: Treating Depression Medications to treat depression are discussed
Treatment for Depression (cont’d.)
• Biomedical treatments:
– Exercise and dietary changes:
• Moderate to intense levels of daily exercise can
significantly reduce residual symptoms of depression
• Omega-3 supplementation
– Circadian-related treatments:
• Sleep deprivation followed by sleep recovery
• Light therapy
Treatment for Depression (cont’d.)
• Biomedical treatments:
– Brain stimulation therapies:
• Used for severe or chronic depression
• Electroconvulsive therapy (ECT)
– Applies moderate electrical voltage to brain to produce
convulsions
• Vagus nerve stimulation
– Alone and combined with ECT
• Transcranial magnetic stimulation
– Electromagnetic field stimulates that brain
Treatment for Depression (cont’d.)
ABC Video: Magnetic Stimulation to the Brain An experimental method called
repetitive transcranial magnetic stimulation (TMS treats depression with pulsating
magnets).
Treatment for Depression (cont’d.)
• Psychological and behavioral treatments:
– Behavioral activation therapy:
• Focus of treatment is increasing exposure to
pleasurable events and activities, improving social
skills, and facilitating social interactions via steps:
– Identifying and rating activities in terms of pleasure and
mastery
– Feeling pleasure or mastery after performing them
– Identifying problems and using techniques to solve them
– Improving social and assertiveness skills
Treatment for Depression (cont’d.)
• Psychological and behavioral treatments:
– Interpersonal psychotherapy:
• Depression occurs within interpersonal context,
relationship issues are target
• Clients learn to evaluate their role in conflicts ad make
positive changes in their relationships by:
– Improving communication with others, identifying role
conflicts, and increasing social skills
• Geared toward present, not past, relationships
Treatment for Depression (cont’d.)
• Psychological and behavioral treatments:
– Cognitive-behavioral therapy:
• Focus is on altering negative thought patterns and
distorted thinking associated with depression
• Clients are taught to:
– Identify negative, self-critical thoughts
– See the connection between negative thoughts and
subsequent feelings
– Replace inaccurate thoughts with realistic interpretations
Treatment for Depression (cont’d.)
• Psychological and behavioral treatments:
– Mindfulness-based cognitive therapy:
• Calm awareness of one’s present experience, thoughts
and feelings, and promotes an attitude of acceptance
rather than judgment, evaluation, or rumination
• Disrupt the cycle of negative thinking by focusing on
present
Treatment for Depression (cont’d.)
• Combining biomedical and psychological
treatments:
– Current treatments often produce symptom
remission
– Antidepressants are effective in severe cases of
depression, but temporary
– Psychotherapies have longer-lasting effects
– Advantages of combining medication and
psychotherapy
Bipolar Disorders
• Involves symptoms of mania/hypomania that
may alternate with episodes of depression
• Differ from depressive disorders in terms of:
– Genetics
– Treatment
– Age of onset
– Prevalence
Bipolar Disorders (cont’d.)
Bipolar Disorder: Mary, Parts 2 and 3 Interview with Mary, who suffers from bipolar
disease and manic depression, part two and three
Diagnosis and Classification of Bipolar
Disorders
• Diagnosed based on evaluation and
confirmation of hypomanic or manic
symptoms
• Severity and pattern of depressive symptoms
are also reviewed
• Three types of bipolar disorders:
– Bipolar I
– Bipolar II
– Cyclothymic disorder
Diagnosis and Classification of Bipolar
Disorders (cont’d.)
Figure 7-4 Mood States Experienced in Bipolar Disorder All individuals diagnosed
with a bipolar disorder have experienced at least one episode of elevated mood (mania
or hypomania). Many also experience periods of mild, moderate, or severe depression.
Source: National Institute of Mental Health, 2012. Retrieved from
http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml
Diagnosis and Classification of Bipolar
Disorders (cont’d.)
• Bipolar I:
– At least one manic episode (with or without a
history of severe depression)
– Approximately 25% experience rapid-cycling
• Bipolar II:
– At least one major depressive episode lasting at
least two weeks and at least one hypomanic
episode lasting at least four consecutive days
• Approximately one-third exhibit rapid-cycling
and mixed episodes
Diagnosis and Classification of Bipolar
Disorders (cont’d.)
• Primary distinction between Bipolar I and
Bipolar II is severity of symptoms during
energized episodes
• Bipolar I diagnosis requires that symptoms be:
– Severe enough to be considered manic
– Ongoing for at least one week
– Severe enough to significantly impair social or
occupational functioning
Diagnosis and Classification of Bipolar
Disorders (cont’d.)
• Cyclothymic disorder:
– Hypomanic episodes are consistently interspersed
with depressed moods for at least two years
– Never symptom free for more than two months
– Similar to dysthymic disorder due to chronicity of
mood symptoms, but differs due to presence of
periodic hypomanic symptoms
How Common Are Bipolar Disorders?
• Far less prevalent than depressive disorder
• Onset usually occurs in adolescence or early
adulthood
• Cyclothymia is les common than chronic
depressive disorder
• No marked gender differences in bipolar I, but
bipolar II is more frequent in women
• High cost
• Comorbid conditions
How Common Are Bipolar Disorders?
(cont’d.)
Figure 7-2 12-Month and Lifetime Prevalence of Depressive and Bipolar Disorders
Source: Based on Hasin, Goodwin, et al. (2005); R.C. Kessler, Berglund, Demier, Jin, Koretz, et
al. (2003); Merikangas, Akiskal, et al. (2007).
Etiology of Bipolar Disorders
• Biological dimension:
– Heritability in bipolar disorder is well established
– Complex genetic basis involving interactions
among multiple genes, including circadian-related
genes
– Neurological influences
• Irregularities in way brain processes and responds to
stimuli associated with reward
• Hypersensitive neurological systems
– Ambiguous goal setting and sleep deprivation
Etiology of Bipolar Disorders (cont’d.)
• Biological dimension:
– Dysregulation in brain activation systems
– Disruptions in stress circuitry of brain
• Increased levels of glutamate
– Brain irregularities
• Emotional regulation areas
– Traumatic brain injury
Etiology of Bipolar Disorders (cont’d.)
• Commonalities between bipolar disorders and
schizophrenia:
– Chronic disorders with clear neurological
irregularities
– Genetic, neuroanatomical, and cognitive
abnormalities
• Overlap in affected brain regions
• Similar gray matter abnormalities
• Similar cognitive deficits: poor insight into appropriate
behavior, confused thought processes
Etiology of Bipolar Disorders (cont’d.)
• Commonalities between bipolar disorders and
schizophrenia:
– Noncompliance with medication regimes due to
poor insight and lack of illness awareness
– Neurocognitive deficits affecting social
competence and daily functioning
– Significant psychosocial and vocational
impairment
Treatment for Bipolar Disorders
• Therapy aims to eliminate all symptoms
– Residual symptoms increase relapse rate
• Focus on preventing future episodes
• Combination of mood-stabilizing medications
and psychoeducation
• Lithium is treatment of choice
– Stabilizes mood and prevents hospitalization
– Decreased suicide risk
– Serious side effects
Treatment for Bipolar Disorders
(cont’d.)
• Anticonvulsant drugs are also being used
• Antidepressants are added to deal with
depressive symptoms, but they may
exacerbate hypomanic/manic symptoms
• Issue of noncompliance with lithium and other
mood stabilizers
Treatment for Bipolar Disorders
(cont’d.)
• Psychotherapy and family therapy have also
proven helpful
– Psychoeducation, family-focused, interpersonal,
and cognitive-behavioral therapy reduce symptom
severity, prevent relapse, and enhance
psychosocial functioning
• Social rhythm therapy:
– Creation of day-to-day routines
• Mindfulness helps regulate mood
• Light therapy and ECT are rarely used