Mood disorders
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Mood Disorders. Mood Disorders. Involve severe and enduring disturbances in emotionality Range from elation to severe depression Depression Bipolar Disorder. Mental Health Resources at UD. Center for Counseling and Student Development 831-2141 Psychological Services Training Center

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Mood disorders

Mood Disorders

Mood disorders1

Mood Disorders

  • Involve severe and enduring disturbances in emotionality

  • Range from elation to severe depression

  • Depression

  • Bipolar Disorder

Mental health resources at ud

Mental Health Resources at UD

  • Center for Counseling and Student Development

    • 831-2141

  • Psychological Services Training Center

    • 831-2717 (Sliding scale)

  • Delaware Help Line

    • 1-800-464-HELP

Mood disorders overview

Mood Disorders Overview

  • Symptoms, onset, prevalence (Depression, Bipolar)

  • Causes (Depression, Bipolar)

  • Suicidality

  • Treatment of Depression

  • Treatment of Bipolar

Depressive disorders

Depressive Disorders

  • There are several types:

    • Major depression

    • Dysthymia

    • Double depression

    • Seasonal Affective Disorder

    • Postpartum Depression

    • Childhood Depression

Symptoms of major depression

Depressed Mood (Irritable in children)

Decreased interest in activities

Weight or appetite changes

Sleep changes

Psychomotor agitation or retardation

Fatigue/loss of energy

Feelings of worthlessness or excessive guilt

Concentration problems

Thoughts of death, suicide, or suicide attempt

Distress or impairment

Not associated grief

Symptoms of Major Depression

Onset and duration

Onset and Duration

  • Age of onset = 25 years

  • Avg episode length = 6 months

  • Recurrent, especially w/ early onset (50, 70, 90)

  • Median # of episodes = 4

  • Most no treatment

  • Earlier onset = poorer prognosis, more chronicity, worse response to treatment

Gender differences

Gender Differences

  • Equal among boys and girls

  • 2:1 women

  • 25% female lifetime prevalence (12% male)

Historical changes

Historical Changes

  • Depression in youth increased 10x (2 generations)

    • Age of onset is decreasing

    • 25% of those aged 18-29 one episode (2003)

  • Symptoms vary by age and culture

Cultural differences

Cultural Differences

  • African American rates similar to Caucasian

  • Asian Americans lowest rates

    • 0.8% report lifetime prevalence

    • 0.8% dysthymia

  • Less common among recently immigrated Hispanics vs. Hispanic Americans (who have rates similar to Caucasians)

    • Can cope better? Stress of immigration?



  • Chronic (2 years)

  • Same symptoms, but less severe (but still debilitating)

  • Entire life

  • Lifetime prevalence 6%

  • Few seek treatment

    • Personality?

Seasonal affective disorder

Seasonal Affective Disorder

  • Develops in late fall/early winter

  • Remits in spring

  • Prevalence = 3%

  • Length of day/avg temp?

  • Iceland low (expect high)

  • Changes in hormone with seasons?

    • Melatonin up in winter

Postpartum depression

Postpartum Depression

  • During first few weeks post-delivery

  • (not postpartum blues - 50-80%)

  • Massive hormone change as trigger?

  • Other hormone changes similar

    • Oral contraceptives, puberty, menopause

Childhood depression

Childhood Depression

  • Occurring more frequently & earlier

  • Is this the same as adult depression?

    • Different cognitive/emotional development

    • Gender rates equal until teens

    • Symptom patterns look different, not as “obvious”

  • Predictive of adult depression

When depression is not depression

When Depression is Not Depression

  • Bereavement (not diagnosed up to 2 months)

  • Adjustment disorders

  • Medical conditions

    • “Depression due to a general medical condition”

  • Everyone experiences normal sadness

    • Difficulty coping, interferences with daily activities

What is bipolar disorder

What is Bipolar Disorder?

  • Experience of mania

    • Excessive energy

    • Decreased need for sleep

    • Rapid speech (pressured speech) & movement

    • Impulsive and/or dangerous behavior

      • Spending sprees, investments

      • Unsafe sexual behavior

  • Hypomania = less severe mania

What is bipolar disorder1

What is Bipolar Disorder?

  • Extreme shifts between mania & depression (days to months)

  • Lifetime prevalence = 1% - 5%

  • Equal rates across gender, culture

  • Early onset = more severe & more chronic

Bipolar disorder

Bipolar Disorder

  • Avg age onset 18 (I) and 22 (II)

    • 50% patients ill before age 30 (25% by 20)

  • Course is unpredictable

  • Diagnosis is often delayed

  • 10-15% of patients commit suicide

    • 20-50% will attempt at some point

Bipolar disorder in children

Bipolar Disorder in Children

  • Irritability, emotional swings

  • More chronic (not episodic)

  • Often misdiagnosed (ADHD, Conduct Disorder)

Causes of depression and bipolar disorder

Causes of Depression and Bipolar Disorder

Causes of depression

Biological Dimensions

Psychological Dimensions

Social and Cultural Dimensions

Integrative Theory

Causes of Depression

Familial and genetic influences

Familial and Genetic Influences

  • 36-44% heritable women, 18-24% men (major depression)

  • Stronger genetic influences bipolar

Familial and genetic influences1

Familial and Genetic Influences

  • Certain pattern most genetic, depression:

    • Early age of onset

    • Greater number of episodes

    • Long longest episode

    • More impairment

    • Suicidality

  • Probably polygenic

Neurotransmitter systems

Neurotransmitter Systems

  • Low relative levels of serotonin

    • Serotonin = regulation of emotional reactions

  • Indirect evidence

    • Metabolites of serotonin & norepinephrine lower

    • Drugs increasing serotonin help

    • Drugs decreasing serotonin ruin the effects of antidepressants

    • Receptors abnormal (PET)

Neuroendocrine influences

Neuroendocrine Influences

  • Hormonal diseases can = depression

    • E.g. Hypothyroidism

  • Cortisol (stress hormone) is elevated

    • May not be specific to depression

  • Hormones likely associated with post-partum depression

Circadian rythyms sleep disturbances

Circadian Rythyms & Sleep Disturbances

  • Excess vs. lack

  • Falling asleep, waking up, early waking

  • Circadian rythym: Our normal daily pattern of biological changes (hormones)

How do depressed people sleep

How do depressed people sleep?

  • Shortened REM latency (quick)

    • Sooner, longer, more intense

  • Expense: deep sleep

    • Energy restoring

Sleep of nondepressed individuals

Sleep of Nondepressed Individuals

Sleep for depressed

Sleep for Depressed

Sleep disturbances

Sleep Disturbances

  • Early awakening an early marker?

  • General poor sleepers?

    • Influence treatment?

  • Sleep as predictor

    • Reduced REM latency more pronounced in absence of stressful life event

  • A biological process that can bring on depression alone?

Psychological perspectives on depression

Psychological Perspectives on Depression

  • Stressful Life Events

  • Learned Helplessness

  • Negative Cognitive Styles

  • Behavioral Approaches

Stressful life events

Stressful Life Events

  • Strongly related to onset

  • 80% of depressive episodes, in community samples, preceded by event

  • Stronger predictor initial episode

  • Poorer response to treatment

  • Longer recovery

  • Increased chance recurrence

Stressful life events1

Stressful Life Events

  • Relationship breakup

    • 10x increase over twin

  • Humiliation

    • 20x increase in depressive episode than a twin with same genes, but no event

Learned helplessness model

Learned Helplessness Model

  • Seligman’s dogs

  • Learned helplessness: depression as a result of aversive situations which we cannot control

  • Or, attributions of lack of control

Learned helplessness model1

Learned Helplessness Model

  • Attributions:

    • Internal/external

    • Global/specific

    • Stable/unstable

  • Worst combination:

    • Internal + global + stable

    • “It is all my fault, always. Additional bad things will always be my fault”

Cognitive model beck

Cognitive Model (Beck)

  • Development of depression

    • How do we think about ourselves?

    • How do we think about the world?

Cognitive triad self world future

Cognitive triad (Self, World, Future)




Cognitive model beck1

Cognitive Model (Beck)

  • Depression = interpreting many events in negative ways

  • Cognitive errors

    • Overgeneralization

    • Arbitrary influence

Cognitive model some examples

Cognitive Model (Some Examples)

  • Normal disappointments are unbearable

  • I am deficient, especially at handling stress that other people can handle

  • My future is hopeless. My stress will never end and there is nothing I can do to help

The behavioral component

The Behavioral Component

  • Behaviors reinforce/maintain depressive feelings

    • E.g. withdraw from society b/c depression leaves people with little energy

    • BUT withdrawing from society minimizes chance they will experience fun and feel better

    • A cycle -> behaviors maintain symptoms

Social and cultural influences

Social and Cultural Influences

  • Marital Relations

  • Gender Differences

  • Social Support

Marital relations

Marital Relations

  • Strongly related to depression

  • Marriage seems to have greater impact on men’s depression

  • Depression may erode relationships

Gender differences1

Gender Differences

  • 70% of individuals with depression are women

  • Consistent across cultures

  • Uncontrollability, due to socialization?

  • Differences in rumination

  • Social disadvantages

Social support

Social Support

  • Major buffer

  • Brown et al: of women experiencing a stressful event, only 10% of those who became depressed had a confidante

  • Faster recovery

Causes of bipolar disorder

Causes of Bipolar Disorder

  • Biological Dimensions

  • Psychological Dimensions

  • Social and Cultural Dimensions

  • Integrative Theory

Familial and genetic influences2

Familial and Genetic Influences

  • Stronger genetic than depression

  • Risk in 1st degree relatives 10x general pop.

  • Attempts to isolate genes unsuccessful



  • Depression = low levels serotonin & NP

  • Mania = high levels of NP

    • Lithium reduces NP

  • No evidence serotonin is involved

Sleep and circadian rhythms

Sleep and Circadian Rhythms

  • Bipolar patients show sensitivity to light

    • More suppression of melatonin when exposed to light at night

    • Regulates sleep

  • Insomnia can trigger manic episodes

Stressful life events2

Stressful Life Events

  • Also strong relationship

    • Especially early mania

  • Can also prevent recovery

  • Upward spiral of positive events

  • Severe will trigger for 50%

  • Disrupted social interactions worst

Social support1

Social Support

  • Speeds recovery from depressive, not manic, episodes

Bipolar disorder in children1

Bipolar Disorder in Children

  • Underdiagnosis vs. overdiagnosis

  • Prevalence likely same as adult

  • BUT earlier age of onset w/ later age of birth

  • 20-40% of adults report childhood onset

What do bipolar children look like

What do Bipolar Children Look Like?

  • Difficult to see? (Happy = good)

  • Delusions of grandeur & failure of logic

    • How to teach classes

    • Permission to steal

    • Prominent profession, despite failing

  • Lots of activity before bedtime & difficulty falling asleep

  • Pressured speech & racing thoughts

What do bipolar children look like1

What do Bipolar Children Look Like?

  • Minor changes in environment increase distractibility

  • Increased motor activity

  • Increased goal-directed behavior

  • Pleasurable, high-risk activities

    • Hypersexuality

    • Spending money

    • Reckless behavior (e.g. driving, drinking)

What else does bipolar look like in children

What Else Does Bipolar Look Like in Children?

  • Sexual Abuse

  • Language Disorders

  • ADHD - 30% comorbidity

  • Conduct Disorder - 18% comorbidity

  • Schizophrenia - history of mania?

  • Substance Abuse

How is this different from adults

How is this different from Adults?

  • Continuous rapid cycling, rather than discrete episodes

  • Initial episode is depression, not mania

  • No inter-episode normal functioning (perhaps even no inter-episode period)

What do we need to know

What do we need to know?

  • How to treat childhood BP (because outcomes may be worse)

  • Better education re: diagnosis

  • More research on treatment

    • Are the same meds safe?

    • Do we need psychosocial interventions?

  • Epidemiological research on rates, etc.





  • Most commonly associated with depression

  • Common with other disorders

    • Schizophrenia

    • Substance abuse

    • Borderline Personality Disorder

  • Large stigma = more common than know

Statistics on suicidality

Statistics on Suicidality

  • 8th leading cause of death 25-34 year olds

  • Actual number is likely 2-3x higher

    • Difficult to estimate

  • Increase among teenagers (3rd leading cause)

    • 200% increase 1960-1988

  • 10-25% college students thoughts

Attempts gender differences

Attempts, Gender Differences

  • Most people do not succeed

  • Women 3x more likely attempt, Men 4-5 more times likely to succeed

Why gender differences

Why Gender Differences?

  • College students - men/women who complete are more masculine

  • Women who survive an attempt = less stigma?

  • Men choose more fatal methods

Risk factors

Risk Factors

  • Family history

    • 6x increase in offspring of attempters

  • Low levels of serotonin (impulsivity, overreactions, instability)

  • Psychological disorder

    • 90% of completers have a mental health disorder

    • Especially impulsive disorders (Borderlines)

  • Alcohol use

    • 25-50% of suicides

Risk factors1

Risk Factors

  • Previous attempts

  • Hopelessness (above depression & ideation)

  • Meaningless or lack of purpose? (Especially for men)

  • Feelings of being a burden

  • Prior exposure to pain

  • Intent andaccess

Misconceptions of suicide

Misconceptions of Suicide

  • People who talk about it are unlikely to commit it

    • OR People who do it don’t talk about it

  • People who commit suicide are irrational

  • People who commit suicide are all very depressed

  • Asking people whether they are suicidal increases their risk

    • Can decrease due to intervention

  • People commit suicide b/c of the way they feel

Treatment of depression and bipolar disorder

Treatment of Depression and Bipolar Disorder

Types of treatment

Types of Treatment

  • Medication

  • Electoconvulsive Therapy and Transcranial Magnetic Stimulation

  • Psychological Treatments

Medications for depression

Medications for Depression

  • Tricyclic Antidepressants

  • Monoamine oxidase inhibitors (MAOIs)

  • Selective Serotonergic Reuptake Inhibitors (SSRIs)

Medication for bipolar disorder lithium

Medication for Bipolar Disorder - Lithium

  • Serious side effects = close regulation

  • Mechanism unclear

  • 30-60% patients good response

  • Prevent mania in 66% of patients

  • Compliance is a concern

Electroconvulsive therapy transcranial magnetic stimulation

Electric shock to brain for < 1 second

Produces seizure

6-10 treatments, every other day

Some memory loss and confusion

Magnetic coil generates localized electromagnetic pulse

Electroconvulsive Therapy & Transcranial Magnetic Stimulation

Psychological treatments for depression

Psychological Treatments for Depression

  • Cognitive Therapy

  • Interpersonal Therapy

  • Behavior Therapy

Cognitive therapy for depression

Cognitive Therapy for Depression

  • Examine thought processes, recognize errors

  • Examine negative automatic thoughts

  • Later examine negative schemas

Interpersonal psychotherapy

Interpersonal Psychotherapy

  • Disruptions of relationships often lead to depression

  • Four general interpersonal areas:

  • Interpersonal role changes

  • Loss of relationships

  • Acquiring new relationships

  • Social Skills deficits

Preventing relapse

Preventing Relapse

  • Maintenance treatment – prevents relapse

  • CT reduces relapse by more than 50% vs. meds

Mindfulness based cognitive therapy

Mindfulness-Based Cognitive Therapy

  • Developed specifically for relapse prevention

  • MBCT vs CT

    • Patients with 3+ episodes do better in MBCT

Psychotherapy for bipolar disorder

Psychotherapy for Bipolar Disorder

  • Focus on increasing medication compliance

  • Interpersonal & Social Rhythm Therapy

    • Regulate sleep

    • Daily schedules

    • 56% recover, vs. 20% drug alone

Psychotherapy for bipolar disorder1

Psychotherapy for Bipolar Disorder

  • Family tension can predict relapse

    • Understand symptoms

    • New coping skills

    • Communication styles

    • Prevent relapse

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