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Mood Disorders Mood Disorders 1. 2. 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 Psychological Services Training Center 831-2141 831-2717 (Sliding scale) Delaware Help Line 1-800-464-HELP Mood Disorders Overview Symptoms, onset, prevalence (Depression, Bipolar) Causes (Depression, Bipolar) Suicidality Treatment of Depression Treatment of Bipolar 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 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 Equal among boys and girls 2:1 women 25% female lifetime prevalence (12% male) 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 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 Chronic (2 years) Same symptoms, but less severe (but still debilitating) Entire life Lifetime prevalence 6% Few seek treatment Personality? 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 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 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 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? 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 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 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 Irritability, emotional swings More chronic (not episodic) Often misdiagnosed (ADHD, Conduct Disorder) Causes of Depression and Bipolar Disorder Causes of Depression Biological Dimensions Social and Cultural Dimensions Psychological Dimensions Integrative Theory Familial and Genetic Influences 36-44% heritable women, 18-24% men (major depression) Stronger genetic influences bipolar 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 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 Hormonal diseases can = depression Cortisol (stress hormone) is elevated E.g. Hypothyroidism May not be specific to depression Hormones likely associated with post-partum depression 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? Shortened REM latency (quick) Sooner, longer, more intense Expense: deep sleep Energy restoring Sleep of Nondepressed Individuals Sleep for Depressed Sleep Disturbances Early awakening an early marker? General poor sleepers? Sleep as predictor Influence treatment? Reduced REM latency more pronounced in absence of stressful life event A biological process that can bring on depression alone? Psychological Perspectives on Depression 1. 2. 3. 4. Stressful Life Events Learned Helplessness Negative Cognitive Styles Behavioral Approaches 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 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 Seligman’s dogs Learned helplessness: depression as a result of aversive situations which we cannot control Or, attributions of lack of control 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) Development of depression How do we think about ourselves? How do we think about the world? Cognitive triad (Self, World, Future) Self World Future Cognitive Model (Beck) Depression = interpreting many events in negative ways Cognitive errors Overgeneralization Arbitrary influence Cognitive Model (Beck) Maladaptive schemas - seeds Way we organize the world How we experience life, the way we feel about us and the world Children with maladaptive schemas distort perceptions & at risk 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 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 Marital Relations Gender Differences Social Support Marital Relations Strongly related to depression Marriage seems to have greater impact on men’s depression Depression may erode relationships Gender Differences 70% of individuals with depression are women Consistent across cultures Uncontrollability, due to socialization? Differences in rumination Social disadvantages 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 Biological Dimensions Psychological Dimensions Social and Cultural Dimensions Integrative Theory Familial and Genetic Influences Stronger genetic than depression Risk in 1st degree relatives 10x general pop. Attempts to isolate genes unsuccessful Neurotransmitters Depression = low levels serotonin & NP Mania = high levels of NP Lithium reduces NP No evidence serotonin is involved 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 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 Support Speeds recovery from depressive, not manic, episodes 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? 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 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? 1. 2. 3. 4. 5. 6. Sexual Abuse Language Disorders ADHD - 30% comorbidity Conduct Disorder - 18% comorbidity Schizophrenia - history of mania? Substance Abuse How is this different from Adults? 1. 2. 3. 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? 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. Suicidality 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 8th leading cause of death 25-34 year olds Actual number is likely 2-3x higher Increase among teenagers (3rd leading cause) Difficult to estimate 200% increase 1960-1988 10-25% college students thoughts Attempts, Gender Differences Most people do not succeed Women 3x more likely attempt, Men 4-5 more times likely to succeed 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 Family history Low levels of serotonin (impulsivity, overreactions, instability) Psychological disorder 6x increase in offspring of attempters 90% of completers have a mental health disorder Especially impulsive disorders (Borderlines) Alcohol use 25-50% of suicides 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 and access Misconceptions of Suicide People who talk about it are unlikely to commit it 1. • People who commit suicide are irrational People who commit suicide are all very depressed Asking people whether they are suicidal increases their risk 2. 3. 4. • 5. OR People who do it don’t talk about it Can decrease due to intervention People commit suicide b/c of the way they feel Treatment of Depression and Bipolar Disorder Types of Treatment 1. 2. 3. Medication Electoconvulsive Therapy and Transcranial Magnetic Stimulation Psychological Treatments Medications for Depression 1. 2. 3. Tricyclic Antidepressants Monoamine oxidase inhibitors (MAOIs) Selective Serotonergic Reuptake Inhibitors (SSRIs) 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 Psychological Treatments for Depression 1. 2. 3. Cognitive Therapy Interpersonal Therapy Behavior Therapy Cognitive Therapy for Depression Examine thought processes, recognize errors Examine negative automatic thoughts Later examine negative schemas Interpersonal Psychotherapy 1. 2. 3. 4. 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 Maintenance treatment – prevents relapse CT reduces relapse by more than 50% vs. meds Mindfulness-Based Cognitive Therapy Developed specifically for relapse prevention MBCT vs CT Patients with 3+ episodes do better in MBCT 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 Disorder Family tension can predict relapse Understand symptoms New coping skills Communication styles Prevent relapse