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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 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?


Dysthymia
Dysthymia

  • 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

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 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 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


Neurotransmitters
Neurotransmitters

  • 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.



Suicidality1
Suicidality

  • 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



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