Download Mood Disorders: An overview

MOOD DISORDERS:
AN OVERVIEW
CHAPTER 7
Introduction
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Most of us feel depressed from time
to time, but this is not depression.
Mood disorders – involve much more
severe alterations in mood for much
longer periods of time.
The disturbances of mood are intense
and persistent and lead to serious
problems in work and in relationships.
In 2000, depression ranked among
the top five health conditions in the
United States, ranking above heart
disease and stroke.
The direct and indirect cost of
depression is $83.1 billion within the
U.S. This makes up 60% of the
reported costs resulting from problems
in the workplace.
Introduction
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There are many types of
depression recognized in the
DSM-5.
These various types of
depression used to be
called affective disorders.
This means extremes in
emotion or affect – soaring
elation or deep depression.
Having an abnormal mood
is the main symptom.
Mood Disorders: An Overview
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The two key moods involved
in mood disorders are
mania and depression.
Mania – means intense and
unrealistic feelings of
excitement and euphoria.
Depression – involves
extremes of loneliness and
dejection.
Normal mood states can
occur between both types of
episodes.
Types of Mood Disorders
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Uni-polar Depressive Disorders – a
person experiences only
depressive episodes.
Bipolar Disorders – a person
experiences both manic and
depressive episodes.
There are noticeable differences in
the symptoms, causal factors, and
optimal treatments.
Severity – the number of
dysfunctions experienced and the
relative degree of impairment.
Duration – whether the disorder is
acute, chronic, or intermittent.
Types of Mood Disorders
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The most common form of
mood episode that people
present with is a major
depressive episode. The
person must be markedly
depressed for most of the
day and for most days for at
least 2 weeks.
He or she must show at least
3 symptoms: feelings of
worthlessness, guilt, thoughts
of suicide, fatigue, physical
agitation, changes in
appetite, and sleep patterns.
Types of Mood Disorders
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Manic episode – is when a person show a
markedly elevated, euphoric, or expansive
mood, often interrupted by occasional
outbursts of intense irritability or even
violence when people refuse to go along
with the manic person’s wishes and schemes.
These extreme moods must persist for at least
a week for this diagnosis to be made.
Three or more additional symptoms must
occur in the same time period, ranging from
behavioral symptoms (an increase in goaldirected activity), to mental symptoms where
self-esteem becomes grossly inflated and
mental activity may speed up (such as “flight
of ideas” or “racing thoughts” to physical
symptoms (such as a decreased need for
sleep or psychomotor agitation).
Types of Mood Disorders
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In milder forms, similar kinds of
symptoms can lead to a diagnosis of
hypomania episode – in which a person
experiences abnormally elevated,
expansive, or irritable mood for at least
4 days.
The person must have at least three
other symptoms similar to those involved
in mania, but to a lesser degree (e.g.
inflated self-esteem, decreased need
for sleep, flight of ideas, pressured
speech, etc.). Hospitalization is not
always required with this mental illness.
With all these illnesses there are
varying degrees of causal pathways
and treatments. Suicide tends to be a
frequent outcome of significant
depressions, both unipolar and bipolar.
The Prevalence of Mood Disorders
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Major mood disorders occur with
alarming frequency-at least 15-20 times
for frequently than schizophrenia and at
the same rate as all the anxiety
disorders taken together.
Unipolar major depressive disorder
(MDD), in which only major depressive
episodes occur is the most common and
has increased in the last couple decades.
Unipolar depression is always much
higher for women than for men as are
anxiety disorders. This is the same in
most countries of the world. The few
exceptions are Iran and Nigeria and this
trend continues until about 65 years of
age when it seems to disappear. Bipolar
is less common.
Unipolar Mood Disorders
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Feelings of depression are
unpleasant when we are
experiencing them, but they usually
do not last long, dissipating on their
own after a period of days or
weeks or after they have reached
a certain intensity level.
By slowing us down, mild
depression sometimes saves us from
wasting a lot of energy in the futile
pursuit of unobtainable goals.
Depression is more common in
people undergoing painful but
common life events such as
significant personal, interpersonal,
or economic losses.
Loss and the Grieving Process
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We tend to think of grief as the death
of a loved one-a process that tends to
be more difficult for men than for
women.
There are usually 4 phases of normal
response to the loss of a spouse or
close family member: 1) numbing and
disbelief, 2) yearning and searching
for the dead person, 3)
disorganization and despair that sets
in when the person accepts the loss as
permanent, and 4) some
reorganization as the person
gradually begins to rebuild his or her
life. It is easy for a person to become
stuck in one of the phases of grief.
Loss and the Grieving Process
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Grief can also follow
other events such as
marital dissolution,
unexpected economic
misfortunes, or job loss.
If a person does not
grieve these things, they
may not be dealing with
the issue at hand (at least
at a psychological level).
Postpartum “Blues”
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Normally, the birth of the child is seen as a happy event. Postpartum depression
can sometimes occur with a new mother (and sometimes a new father) following
the birth of a child. It can have negative effects on the new child.
Post partum depression was seen in the past as fairly common, but after more
studies it has been shown that postpartum blues tend to be what happens.
The symptoms of postpartum blues include: changeable mood, crying easily,
sadness, irritability, and mixed feelings of happiness. These feelings tend to
occur within 50-70% of women within 10 days after the birth of their child and
usually subside on their own.
It is very rare for women to have major depression with psychotic features.
There is a likelihood of developing major depression after the postpartum blues,
especially if the episode is severe. Hormonal readjustments and alterations in
serotonergic and noradrenergic functioning may play a role in postpartum blues
and depression. If the new mother has a lack of social support or has difficulty
adjusting to her new identity and responsibilities, this may be higher. If the
woman has a history of family depression the risk may be higher as well.
Dysthymic Disorder
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When a mood disorder becomes a
diagnosable mood disorder is up to clinical
judgment that concerns the degree of
impairment.
Dysthymic Disorder – is generally considered
to be mild to moderate in intensity. A person
must have a persistantly depressed mood
most of the day, for more days than not, for
at least 2 years.
2.5-6% of the population will have this
disorder within their lifetime. The average
duration of dysthymia is 4-5 years, but it can
persist for 20 years or more.
Chronic stress has been shown to increase the
severity of symptoms over a 7.5 year period.
Dysthymia tends to begin during the teenage
years. 74% recover within 10 years , but
71% will relapse within 3 years.
Major Depressive Disorder
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The diagnostic criteria for major depressive
disorder means a person must have a major
depressive episode and never have been
manic, hypomanic, or have a mixed episode.
These persons must have a markedly
depressed mood or a loss of interest in
pleasurable activities most of every day,
nearly every day, for at least 2 consecutive
weeks.
The person must have 3 of the 4 symptoms:
cognitive symptoms, feelings of worthlessness
or guilt, and thoughts of suicide, fatigue of
physical agitation, change of sleep, and/or
change of appetite.
There is a high degree of people that have
both depression and anxiety. The loss of
contact with friends tends to happen quite a
bit during depression. The person tends to
be unmotivated to seek contact with their
friends.
Depression as a Recurrent Disorder
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When depression is diagnosed, it is
specified whether it is a first-time or a
recurrent episode.
The cause of depression with women
tends to come from financially
difficulties, severe stressful life events,
and a high genetic risk.
Depressive episodes are usually time
limited. The average untreated
depression is about 6-9 months.
Chronic major depression has been
associated with serious family problems
and an anxious personality in childhood.
Most individuals may be able to get off
the medication, but will relapse because
of environmental issues.
Depression throughout the Life Cycle
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Most unipolar depressive
disorders most often occurs
during late adolescence up
to middle adulthood.
The incidence of depression
rises sharply during
adolescence. 15-20% of
adolescents experience
major depressive disorder
at some point. This is when
sex differences first begin to
emerge.
Depression throughout the Life Cycle
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Major depression that shows up
in adolescence is very much
likely to show up in adulthood.
Those individuals that live in
nursing homes tend to have
higher depression than those
that continue to stay in their
home.
Diagnosing older people can
tend to be more difficult to
diagnose because their
symptoms overlap with other
medical problems.
Specifiers for Major Depressive
Episodes
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One specifier is a major depressive
episode with melancholic features. This
happens when a person has lost interest in
almost all activities. This tends to be more
heritable than other forms of depression
and is often associated with childhood
trauma. These individuals tend to have
significant cognitive impairment.
Psychotic symptoms (the loss of contact
with reality and delusions (false beliefs) or
hallucinations (false sensory perceptions),
may rarely accompany major depression.
This is called a severe depressive episode
with psychotic features. The mood
congruent is generally negative in tone
and may include: personal inadequacy,
guilt, deserved punishment, death, or
disease. Treatment tends to include
antidepressants and antipsychotics.
Specifiers for Major Depressive
Disorders
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The other depressive issue involves
atypical features. Major
depressive episodes with atypical
features include a pattern of
symptoms characterized by mood
reactivity; the person’s mood
brightens in response to potential
positive events.
Females tend to have atypical
features with depression. They
tend to have an earlier onset and
are more likely to show suicidal
thoughts. These individuals tend to
respond to a different class of
antidepressants – the monoamine
oxidase inhibitors.
Specifiers for Major Depressive
Disorders
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Another specifier is used when the
individual shows marked psychomotor
disturbances. Major depressive episodes
with catatonic features include a range of
psychomotor symptoms, from motoric
immobility as well as mutism and rigidity.
Catatonic features are very common with
depression.
Another specifier is shown with people
that have recurrent major depressive
episodes with a seasonal pattern, also
known as seasonal affective disorder. The
person must have had two episodes of
depression in the past 2 years occurring
at the same time of the year (most
commonly fall and winter). Full remission
tends to occur within the spring. This tends
to be seen in higher latitudes and with
younger individuals.
Causal Factors in Unipolar Mood
Disorders
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A variety of diseases and drugs can affect
mood, leading sometimes to depression or to
elevation or even mania.
Family studies have shown that the
prevalence of mood disorders is
approximately 2-3 times higher among
blood relatives of persons with clinically
diagnosed unipolar depression than in the
population at large.
Twins studies have also shown a moderate
genetic contribution. The estimates are
substantially higher for more severe, earlyonset, or recurrent depressions.
There is an even larger heritable link for
families and bipolar disorder. Geneticists are
still looking for genes concerning depression
and bipolar disorder.
Neuro-chemical Factors
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Since the 1960’s, researchers have
concluded that neurotransmissions deal
directly with depression. It was in the
1960’s and 70’s that researchers focused
on two neurotransmitter substances of the
monoamine class – norepinephrine and
serotonin, because antidepressant
medications seemed to have the effect of
increasing these neurotransmitters
availability at synaptic junctions.
This means that depression may originate
from a lack of these neurotransmitters within
the brain.
It has been concluded that no straightforward mechanism could possibly be
responsible for causing depression.
Antidepressants do not seem to have much
impact for 2-4 weeks.
Neuro-Chemical Factors
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It was later figured out that dopamine
played a significant role in depression
including depression with atypical
features and bipolar depression.
Since dopamine is involved with
pleasure and reward, it would make
sense concerning the symptoms.
In the last 20-25 years, scientists have
focused on the complex interactions of
neurotransmitters and how they affect
cellular functioning. Neurotransmitters
may have dysfunctions as they try to
interact with some hormones or
biological rhythms. Scientists question
how these chemicals deal with too much
stress within the body.
Neurophysiological and
Neuroanatomical Influences
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Researchers have found that damage
to the left anterior prefrontal cortex
often leads to depression. This takes
place with brain damage to this
area. Some individuals with
depression may have a lowered
activity in this portion of the brain.
When an EEG is administered to
someone with depression, there is a
lowered functioning or imbalance in
one side of the brain as compared to
the other. People with depression
show a much lower activity in the left
hemisphere of the brain. Similar
findings have been shown with the
PET scan.
Neurophysiological and Neuroanatomic
Influences
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Patients in remission from depression
show the same type of hemisphere
dominance as do children that are at
risk for depression.
Prolonged depression also leads to
decreased hippocampal volume, at
least in older people with depression.
This could be due to cell atrophy or cell
death.
The amygdala, which is involved in
perception of threat and in directing
attention, tends to show increased
activation in individuals with depression,
which might be related to biased
attention to negative emotional
information.
Sleep
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Sleep has 5 stages that occur in a
relatively invariant sequence throughout
the night. REM sleep (rapid eye
movement) is characterized by rapid eye
movements and dreaming as well as other
bodily changes.
The first REM period does not usually
begin until near the end of the first sleep
cycle, about 75-80 minutes into sleep.
Patients who are depressed often show
one or more of a variety of sleep
problems, ranging from early morning
awakening, periodic awakening during the
night, and/or difficulty falling asleep.
These changes occur in about 80% of
hospitalized patients with depression and
in about 50% of outpatients with
depression.
Sleep
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Research using EEG has found that
patients with depression enter the
first period of REM sleep after
only 60 minutes or less of sleep
and also show greater amounts of
REM sleep during the early cycles
than are seen in persons without
depression.
The intensity and frequency of
their rapid eye movements are
also greater than in patients who
are not depressed. This person
tends to get lower than the
amount of deep sleep present
because REM has taken over.
Circadian Rhythms
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Humans have a circadian
rhythm (24 hour or daily) that
includes cycles of sleep,
including body temperature,
propensity to REM sleep, and
secretion of cortisol, thyroid
stimulating hormone, and
growth hormone.
Research has found some
abnormalities in all of these
rhythms in patients with
depression, though not all
patients show abnormalities in
all rhythms.
Sunlight and Seasons
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Another strange disturbance is seen in
people with seasonal affective disorder,
people being influenced by the total light
in the environment.
A majority of these people become
depressed in the fall and winter and
normalize in the spring and summer.
Animals seem to have some of the same
type of changes including: sleep changes,
changes in activity levels, and appetite
shifts.
Patients with Seasonal Affective Disorder
tend to have increased appetite and
sleep longer than usual. They tend to have
circadian rhythms that are off. These
people should use exposure to light (even
artificial light), which can help to
reestablish a rhythm.
Biological Explanations for Sex
Differences
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Hormonal factors such as normal
fluctuations in ovarian hormones
account for sex differences in
depression.
This is only one of the causal
associations that has not yet been
discovered because of real
methodological difficulties in
conducting conclusive research on this
topic.
For a small minority of women who
are already at high risk, hormonal
fluctuations may trigger depressive
episodes, possibly by causing
changes in the normal processes that
regulate neurotransmitter systems.
Psychological Causal Factors – Stressful
Events as Causal Factors
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Psychological stressors are known to be
involved in the onset of a variety of
disorders, ranging from some of the anxiety
disorders to schizophrenia, but nowhere has
their role been more carefully studied than
in the case of unipolar major depression.
These stressful events tend to be the loss of a
loved one, serious threats to important close
relationships or to one’s occupation or severe
economic or serious health problems.
Separations through death or divorce are
strongly associated with depression,
although such losses also tend to precede
other disorders such as panic disorder and
generalized anxiety. Being a caretaker to
someone with a major debilitating disease
(such as Alzheimer’s) can be associated with
the onset of both major depression and
generalized anxiety disorder with the
caretaker.
Stressful Events as Causal Factors
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Sometimes, events that may have been at least partly
generated by the depressed person’s behavior or
personality are stressful, but can be the result of poor
interpersonal problem solving.
Poor problem solving in turn leads to higher levels of
interpersonal stress, which in turn leads to further
symptoms of depression.
Another example is if a person does not pay their
bills, they will have a variety of trouble. These can
sometimes play an even stronger role in the onset of
major depression.
Researchers have felt it important to create a process
that can tell whether or not someone is depression
and/or just perceiving their live events negatively.
Life events were reported and evaluators gave an
average score of someone going through this life
event. The score of participant are then compared. A
woman whose husband left her for a younger woman
would be more stressed out as compared to a woman
that had moved on from a divorce to a new
boyfriend.
Stressful Events as Causal Factors
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Individuals that are
having their first very
stressful episode tend to
be more depressed than
people who have
experienced reoccurring
stressful events.
Mildly Stressful Events and Chronic
Stress
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Good studies have
demonstrated that chronic
stress is associated with
increased risk for the onset,
maintenance, and recurrence
of major depression.
Different studies have used
the term chronic stress (or
chronic strain or difficulties)
and the definition is one or
more forms of stress ongoing
for at least several months
(e.g. poverty, lasting marital
discord, medical disabilities,
having a disabled child).
Vulnerability and Invulnerability
Factors in Responses to Stressors
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Women at genetic risk for
depression not only
experience more stressful
life events, but also are
more sensitive to them.
Personality and Cognitive Diatheses
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Researchers have concluded that
neuroticism is the primary personality
variable that serves as a vulnerability
factor for depression. This refers to a
stable and heritable personality trait that
involves a temperamental sensitivity to
negative stimuli.
People that have high levels of this trait
are prone to experiencing a broad range
of negative moods, including not only
sadness but also anxiety, guilt, and
hostility.
Neuroticism is associated with a worse
prognosis for complete recovery from
depression.
High levels of introversion may also serve
as vulnerability factors for depression,
either alone or when combined with
neuroticism.
Early Adversity as a Diathesis
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A range of adversities in the
early environment (e.g. family
turmoil, parental
psychopathology, physical or
sexual abuse, and other forms
of intrusive, harsh, and
coercive parenting) can create
both short-term and long-term
vulnerability to depression.
There are individuals that
have undergone early
adversity and have remained
extremely resilient.
Beck’s Cognitive Theory
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Aaron Beck, a psychiatrist who became
disenchanted with psychodynamic theories of
depression early in his career, developed his own
cognitive theory of depression.
Beck believed that cognitive symptoms of
depression often precede and cause the affective
or mood symptoms rather than vice versa. Example
– if you think you are stupid and ugly, this may
lead to depression.
Beck’s theory (a diathesis-stress theory) in which
negative cognitions are central, has become
somewhat more elaborate over the years while still
retaining its primary tenets.
There tend to be underlying dysfunctional beliefs,
known as depressogenic schemas, which are rigid,
extreme, and counterproductive.
Beck maintained that simply having these
dysfunctional beliefs – is sufficient to make
someone depressed.
Beck’s Cognitive Theory
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These depression-producing beliefs or schemas are
thought to develop during childhood and
adolescence as a function of one’s negative
experiences with one’s parents and significant
others. This creates a vulnerability to developing
depression.
Negative automatic thoughts – thoughts that often
occur just below the surface of awareness and
involve unpleasant, pessimistic predictions.
Negative cognitive triad – 1) negative thoughts of
the self, 2) negative thoughts about one’s
experiences and the surrounding world, and 3)
negative thoughts about one’s future.
These tend to include: all-or-none reasoning.,
selective abstraction (focusing on the negative detail
of the situation instead of what was positive), and
arbitrary inference – jumping to conclusion based
on minimal or no evidence.
Studies have shown that cognitive behavioral
therapy is very effective given depression.
The Helplessness and Hopelessness
Theories of Depression
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The learned helplessness theory of depression
originated out of observations in an animal research
laboratory. Martin Seligman first proposed that the
lab phenomenon known as learned helplessness
might provide a useful animal model of depression.
Seligman reported that lab dogs who were first
exposed to uncontrollable shocks later acted in
passive and helpless manners when they were in a
situation where they could control the shocks.
This means that when animals or humans find that
they have no control over aversive events (such as
shock), they may learn that they are helpless, which
makes them unmotivated to try to respond in the
future. They show passivity and depressive symptoms.
They are slow to learn that any response they may
make is effective.
Depressed animals show lower levels of aggression,
loss of appetite and weight, and changes in
monoamine neurotransmitter levels.
The Reformulated Helplessness Theory
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Abramson proposed that when
people are exposed to
uncontrollable negative events,
they ask themselves why, and
the kinds of attributes that
people make are, in turn,
central to whether they
become depressed.
These investigators proposed
three critical dimensions on
which attributes are made: 1)
2) internal/external,
global/specific, and 3) stable
or unstable.
The Hopeless Theory of Depression
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Abramson proposed that having
a pessimistic attributional style in
conjunction with one or more
negative life events was not
sufficient to produce depression
unless one first experienced a
state of hopelessness.
A hopelessness expectancy – was
defined by the perception that
one had no control over what was
going to happen and by the
absolute certainty that an
important bad outcome was not
going to occur.
The Rumination Response Styles Theory
of Depression
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When some people have depressed
feelings, they tend to focus intently on
how they feel and why they feel that way
– a process called rumination.
Rumination involves a pattern of
repetitive and passive mental activity.
Those people that ruminate on a regular
basis tend to have more depressive
feelings.
Self-focused rumination leads to
increased recall of more negative
autobiographical memories, thereby
feeding into a vicious cycle of depression.
Men are more likely to take part in
distracting activity (or consume alcohol)
when they get depressed. Teaching girls
to distract themselves may help their
mental health.
Lack of Social Support and SocialSkills Deficits
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Women without a close
relationship were more
likely than those with at
least one close confidant
to become depressed if
they experienced a
severely stressful event.
Some people with
depression have social
skills-deficits.
Bipolar Disorders
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Bipolar disorder is the presence of a
major or hypomanic episode with a
period of depression.
A person having a manic episode
tends to feel elevated, euphoric, and
has an expansive mood, which is often
interrupted by occasional outbursts of
intense irritability or even violence –
especially when others refuse to go
along with a manic person’s wishes
and schemes.
These extreme moods must persist for
at least a week for this diagnosis to
be made. There must also be
functioning impairment of
occupational and social functioning,
and hospitalization is often necessary
during manic episodes.
Cyclothymic Disorder
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Some individuals are subject to cyclical mood
changes less severe than the mood swings seen
in bipolar disorder. In the past, these were
referred to as cyclothymic temperament or
personality.
This disorder lacks certain extreme symptoms of
bipolar disorder and lacks psychotic features
such as delusions and marked impairment.
The mood is generally dejected, there is a loss
of pleasure and activities and pastimes. There
might also be low energy, feelings of
inadequacy, social withdrawal, and pessimism.
There may be times of cyclothymia where a
person becomes especially creative and
productive because of increased physical and
mental energy. There must be a two year
period in which numerous periods with
hypomanic and depressed symptoms are
evident. These individuals are at-risk for
developing full-blown bipolar I or II disorder.
Bipolar Disorders (I and II)
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Bipolar I disorder – is
distinguished from major
depressive disorder by at
least one manic episode or
mixed episode.
A mixed episode – is
characterized by symptoms of
both full-blown manic and
major depressive episodes for
at least one week. These were
once thought to be relatively
rare but have been now
reported as more common. The
long-term outcome is not good
for these individuals.
Bipolar Disorders (I and II)
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Bipolar II disorder –
experiences full-blown
manic or mixed episodes but
has experienced clear-cut
hypomanic episodes as well
as major episodes like
bipolar I.
Bipolar II is more common
than bipolar I. About 2-3%
of the population has this.
Bipolar II disorder evolves
into bipolar I in only 5-15%
of cases, suggesting these
disorders are distinct.
Bipolar Disorders (I and II)
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Bipolar disorders occur equally in
males and females. This disorder
tends to begin in adolescence and/or
early adulthood (with an average age
of 18-22).
Most patients with bipolar disorder
experience periods of remission with
they are relatively symptom-free,
although this may occur on only about
50% of the days. 20-30% tends to
experience significant impairment and
mood swings.
60% tend to have chronic
occupational and/or interpersonal
problems between episodes. Events
can be seasonal in nature.
Bipolar Disorders (I and II)
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75% of the time tends to be in a
depressive state and 25% of the time
tends to be manic.
There is a high overlap in symptoms of
those with major depression and being
depressed with having bipolar. People
with bipolar tends to have more
psychotic episodes, psychomotor
retardation, and more substance abuse.
Those with unipolar depression tend to
show more anxiety, agitation, insomnia,
physical complaints, and weight loss.
Most individuals with bipolar are
misdiagnosed with unipolar depression.
The younger that someone is diagnosed,
the more manic episodes that they are
likely to have.
Bipolar Disorders (I and II)
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Individuals with bipolar tends to have more
depressive episodes than people with
unipolar depression. Those individuals that
have rapid cycling generally experience
more than 4 episodes a year.
Luckily, rapid cycling tends to disappear
within about 2 years.
Even with mood stabilizing medications, the
probability of “full recovery” is
discouraging.
There are definitely biological causes for
bipolar disorder. Results from twin studies
also show a biological inheritance tendency.
Serotonin tends to be low in both depressive
and manic phases. Norepinephrine,
serotonin, and dopamine are all involved in
regulating our mood states. Lithium
decreases dopamine activity and are
antimanic.
Bipolar Disorder (I and II)
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Stressful life events appear to be as
important in precipitating bipolar
depressive episodes and there is some
evidence that stress may trigger manic
episodes.
Many patients that suffer from mood
disorders never seek treatment and even
without formal treatment will recover.
More and more people with this disorder
are seeking treatment as lost work and
suffering are difficult to deal with.
There has been a decrease in
psychotherapy and a steady rate of use of
antidepressants. The social stigma of mental
illness is also increasing.
About 40% of those that get treatment for
bipolar are receiving adequate treatment.
Pharmacotherapy
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Anti-depressant, mood stabilizing, and
antipsychotic drugs are all used in
treatment for unipolar and bipolar
disorders.
The first category of antidepressants
was developed in the 1950’s; these
medications are known as monoamine
oxidase inhibitors (MAOI’s) because they
inhibit the action of monoamine oxidase
– the enzyme responsible for breaking
down nerepinephrine and serotonin once
released. These drugs can have
potentially fatal and dangerous sideeffects if certain foods rich in the amino
acid tyramine are consumed (e.g. red
wine, beer, aged cheese, salami). They
are not used very often today unless
other medications have failed.
Pharmacotherapy
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The drug treatment of choice since the
early 1960’s until about 1990 was one
of the standard antidepressants (called
tricyclic antidepressants) because of
their chemical structure, which are known
to increase neurotransmission of the
monoamines.
Only about 50% is there significant
improvement. 50% of people do not
respond to an initial trial of medication
or a combination of medications.
Tricyclics have unpleasant side effects
for some people (dry mouth,
constipation, sexual dysfunction, and
weight gain may occur). Most patients
do not continue the drug long enough to
see the advantages. These drugs are
toxic when taken in large numbers.
Pharmacotherapy
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Physicians tend to choose selective
serotonin reuptake inhibitors (SSRI) even
though they are no more effective than
tricyclics. These medications tend to have
less side effects, but are being overly
prescribed.
In the past decade, a new atypical
antidepressant have also become
increasingly popular, and each has its
own advantages. Bupropion (Wellbutrin)
does not have many side effects
(especially sexual side effects) as the
SSRI’s, but helps people with depression
that gain weight, have loss of energy,
and oversleep.
Vanlafaxine (Effexor) seems superior to
the SSRI’s in the treatment of severe or
chronic depression.
The Course of Treatment with
Antidepressant Drugs
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Antidepressant drugs usually require at
least 3-5 weeks to take effect. If there
are no signs of improvement after about
6 weeks, physicians should try a new
medication because 50% do not
response to the first drug prescribed,
but do to the second drug.
The natural course of untreated
depression typically takes 6-9 months.
Thus, when depressed patients take
drugs for 3-4 months and then stop
because they are feeling better, they
are likely to relapse because their
underlying symptoms are still present.
More episodes of depression can
happen while the person is still on the
medication.
Lithium and other Mood-Stabilizing
Drugs
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Lithium therapy has become widely used as a
mood stabilizer in the treatment of both
depressive and manic episodes of bipolar
depression.
Mood stabilizers have both anti-manic and antidepressant effects.
Lithium – 75% of individuals taking this
medication show at least partial improvement.
Rapid cycling is less likely to happen if the person
is taking antidepressants as well as Lithium. Some
people take Lithium to prevent new episodes.
Lithium therapy can cause lethargy, cognitive
slowing, weight gain, decreased motor
coordination, and gastrointestinal disorders. Longterm use can lead to kidney malfunction and
damage. Many people with bipolar tend to miss
the feeling of manic episodes. If people can
tolerate the side effects, it greatly minimizes the
chance of suicide and successful suicide.
Electroconvulsive Therapy (ECT)
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Antidepressants tend to take 3-4
weeks to produce significant
improvement.
ECT is often used with severely
depressed patients who may
present with an immediate and
serious suicidal risk, including those
with psychotic features.
After about 6-12 treatments ) with
treatments given every other day)
the person tends to get better
within 2-4 weeks. The treatment
induces seizures are delivered
under general anesthesia and with
muscle relaxants. The most
immediate side effect is confusion.
Suicide
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The risk of suicide (taking one’s own life) is a
significant factor in all types of depression.
50-90% of those that complete suicide do
so during a depressive episode or in the
recovery phase.
This tends to happen when the person begins
to emerge in the recovery phase. Even when
suicide is not associated with depression, it
generally follows a different mental illness.
Those with two or more mental disorders
have a much higher risk of suicide.
3% of Americans have made a suicide
attempt in their lives. 9% have experienced
suicidal ideation. Most of these individuals
do not really want to die and they usually
attempt this alone. There is a long-lasting
distress of those that are left behind.