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CHAPTER FIVE
Mood Disorders
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Types of Mood Disorders
Unipolar Mood Disorders
Bipolar Mood Disorders
(previously manic-depression)
Person experiences only
episodes of depression
Person experiences episodes
of mania and in most cases
episodes of depression
Major Depressive Disorder
Bipolar I disorder
Dysthymia
Bipolar II disorder
Cyclothymia
Episodic vs. Continuous
Absence or Presence
• Mood disorders should be thought of as episodic
JAN
FEB
MAR
APR
MAY
JUN
JUL
month
Depressed
AUG
SEP
OCT
NOV
DEC
Chart: MDD & Bipolar Disorder
Bipolar Disorder
Presence or Absence
Presence or Absence
Major Depressive Disorder
1
2
3
4
5
6
7
8
9 10 11 12
Weeks
major depressive episode
1
2
3
4
5
6
7
8
Weeks
major depressive
episode
manic episode
9 10 11 12
Types of Mood Disorders
Unipolar Mood Disorders
Bipolar Mood Disorders
Person experiences only
episodes of depression
Person experiences
episodes of mania and in
most cases episodes of
depression
Major Depressive Disorder
(MDD)
Bipolar I disorder
Dysthymia
Cyclothymia
(previously manic-depression)
Bipolar II disorder
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Depressed Mood vs.
Major Depressive Disorder (MDD)
• Major Depressive Disorder is more than just
feeling depressed
• Sadness alone is insufficient and unnecessary
for a diagnosis
• Severity, intensity, duration and impairment
Symptoms of
Major Depressive Episode
•
Depressed/dysphoric mood
•
Anhedonia – loss of interest or pleasure
•
Weight loss/gain or appetite increase/decrease
•
Insomnia or hypersomnia
•
Psychomotor agitation or retardation
•
Fatigue or loss of energy
•
Feelings of worthlessness or inappropriate guilt
•
Diminished ability to concentrate or make decisions
•
Suicidal ideation, plan or attempt
Criteria for Unipolar Mood Disorder
Major depressive disorder
At least 1 major depressive episode (lasting
at least 2 weeks)
No manic or hypomanic episodes
Symptoms of Dysthymia
• Depressed mood for most of
the day on more days than not
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making
decisions
• Feelings of hopelessness
Chart: Dysthymia
presence or absence
Dysthymia
JAN
'02
MAR
'02
MAY
'02
JUL
'02
SEP
'02
NOV
'02
JAN
'03
MAR
'03
month
dysthymic symptoms
MAY
'03
JUL
'03
SEP
'03
NOV
'03
Criteria for Unipolar Mood Disorder
Major Depressive
Disorder
Dysthymia
At least 1 major
Depressive symptoms for
depressive episode
at least 2 years
(lasting at least 2 weeks)
No manic or hypomanic
episodes
No manic or hypomanic
episodes
Clinical Impairment in
MDD and Dysthymia
• Occupational / Academic
• Social
• Other important domains of life
Exclusion Criteria
• Not due to a general medical condition
(e.g., thyroid condition)
• Not due to substance use (e.g., alcohol)
• Not bereavement – “normal” grief
Depression &
Interpersonal
Relationships
Special Topic
Interpersonal Relationships & Depression
Coyne, 1976
• Questions
• Do people respond differently to depressed patients?
• Do depressed people induce depression and hostility
in others? Are they rejected socially?
• Method
• Students spoke on the phone with either a depressed
outpatient, non-depressed outpatient, or nonpsychiatric control
• Completed questionnaires on mood, perceptions, and
willingness to interact
Interpersonal Relationships & Depression
Coyne, 1976
• Results
Participants were more…
• depressed, anxious & hostile after interacting with
depressed patients than with any other group.
• rejecting of the depressed patients than they were
of any other group.
• likely to reject opportunities for future interaction if
their own mood was depressed following the
conversation.
Interpersonal Relationships & Depression
[Marriage & Depression]
• People who are separated or divorced are the most likely
to be depressed.
• Depression is also higher in those who are nevermarried than those who are married which may suggest
the importance of social support.
• But, if you are in an unhappy marriage that may cause
depression.
• Depression can also lead to marital problems
• NOTE: potentially vicious feedback cycle
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Symptoms of
Manic & Hypomanic Episodes
•
Elevated mood
•
Irritable/angry mood
•
Inflated self-esteem or grandiosity
•
Decreased need for sleep
•
More talkative than usual or pressure
to keep talking
•
Flight of ideas or racing thoughts
•
Distractibility
•
Increase in goal-directed activity or psychomotor agitation
•
Excessive involvement in pleasurable activities that have a
high potential for painful consequences
Manic vs. Hypomanic Episode
Manic Episode
Hypomanic Episode
Symptoms
Same
Same
Duration
1 week
4 days
Severity
Must interfere
with social or
occupational
functioning
Must be noticeable to
others, but not severe
enough to impair
functioning or to require
hospitalization
Criteria for Bipolar Mood Disorder
Bipolar I
Disorder
Mania
At least one
manic episode
Bipolar II
Disorder
At least one
hypomanic
episode
Cyclothymia
At least 2 years of
hypomanic
symptoms
(no manic episodes)
Depression
Not required,
but could have
a major
depressive
episode
At least one
major
depressive
episode
At least 2 years of
depressive
symptoms
(no major depressive
episodes)
Charts: Bipolar I Disorder
Presence or Absence
Bipolar I Disorder
with Major Depressive Episodes
1
2
3
4
5
6
7
8
week
manic episode
major depressive episode
9
10
11
12
Presence or Absence
Bipolar I Disorder
without Major Depressive Episodes
1
2
3
4
5
6
7
8
week
manic episode
9
10
11
12
Charts:
Bipolar II Disorder & Cyclothymia
Presence or
Absence
Bipolar II Disorder
1
2
3
4
5
6
7
8
week
major depressive
episode
hypomanic episode
9 10 11 12
presence or absence
Cyclothymia
JAN MAR MAY JUL
'02 '02 '02 '02
SEP
'02
NOV
'02
JAN MAR MAY
'03 '03 '03
month
dysthmic symptoms
hypomanic symptoms
JUL
'03
SEP
'03
NOV
'03
Chart: Bipolar I Disorder
• As is the case with unipolar mood
disorders, there must be clinical
impairment or distress
• The symptoms cannot be:
• Due to a medical condition
• Due to substance use
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Mood Disorders with Psychotic Features
Delusion
Major
Depressive
Episode:
Moodcongruent
Major
Depressive
Episode:
Mood –
incongruent
Manic
Episode:
Moodcongruent
Manic
Episode:
Moodincongruent
One day I will
be punished for
being such a
bad person.
Aliens are
putting
thoughts
into my
head.
I am the
smartest
person o n
earth and I
will rule the
world.
Someone is
trying to
poison me.
I hear sleigh Voices tell
that I am a bad bells ringing. me how
person.
great I am.
I see purple
monkeys.
Hallucination Voices tell me
Mood Disorders with Postpartum Onset
• Denotes a major depressive or manic episode
beginning within 4 weeks after childbirth
• The available evidence suggests that it is not
caused primarily, if at all, by hormones
• Most women do not get this out of the blue;
most of them have had prior depressive
episodes.
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Epidemiology: Culture
Cross-cultural differences
• Vocabulary and social differences
make this difficult to investigate.
• Symptoms are interpreted differently
and emotions have different
expressions.
• Most studies indicate, however, that
clinical depression is a universal
phenomenon (although symptoms may
vary considerably from culture to
culture).
Lifetime Prevalence of Major Depressive &
Manic Episodes by Race
Manic Episodes
7
6
5
4
3
2
1
0
Percent
Percent
Major Depressive Episodes
6.6
white
4.5
5.6
black hispanic
7
6
5
4
3
2
1
0
0.8
white
1
black
0.7
hispanic
Epidemiology of Mood Disorders
by Gender: Lifetime Prevalence
percent
30
20
10
0
major
depressive
episode
manic
episode
dysthymia
female
male
any mood
disorder
Prevalence of MDD:
Employment & Income
Income
8
7
6
6
5
4
2
0
2.2
3.4
2
6.1
major depressive disorder
currently employed
currently unemployed
unemployed less than 6 months
unemployed more than 6 months
percent
percent
Employment
4
3
2
1
2.9
0
1.8
major depressive disorder
under $15,000
higher than $15,000
Prevalence of MDD by Age
8
18-29
percent
6
30-44
4
45-64
2
65 +
5
7.5
4
0
major depressive disorder
1.4
Epidemiology: Age
• Researchers previously thought
that depression occurred more
frequently in the elderly.
• Mood disorders are less common
among elderly people than they are
among younger adults.
• Certain subgroups of the elderly population, however,
may have high incidence of mood disorders (e.g., those
about to enter residential care).
• Birth cohort trend: Those born after WWII are more
likely to develop mood disorders and have an earlier age
of onset than people from previous generations.
Chart: What is Cohort Effect?
Hypothetical Example
Level of Depression by Age in Year 2000
50
Depression Level
40
40 year olds
20
30
40
50
30
20
10
0
Age Group
year olds
year olds
year olds
year olds
Chart: What is Cohort Effect?
50
Depression Level
40
Hypothetical Example
Level of Depression by Age in Year 2010
50 year olds
20
30
40
50
60
30
20
10
0
Age Group
year
year
year
year
year
olds
olds
olds
olds
olds
Comorbidity: Definition
Comorbidity
• the manifestation of more than one disorder
simultaneously
• Of those with mental disorders, 25% have
two or more disorders.
Comorbidity: Major Depressive Disorder
DISORDERS
DATA FROM
NCS
Social phobia
27.1%
Alcohol dependence
23.5%
PTSD
19.5%
Generalized Anxiety Disorder
17.2%
Conduct disorder
15.2%
Course & Outcome:
Major Depressive Disorder
• Average age of onset is 23 for males and 25 for
females.
• Minimum duration of at least 2 weeks.
• Most people who have major depression will have at
least 2 depressive episodes.
• MDD is frequently a chronic and recurrent
condition.
• Half recover from their episode of major depression
within 6 months; 40% of people who recover relapse
within a year.
Course & Outcome:
Bipolar Disorders
• Onset is usually between ages 18-20.
• Average duration of manic episode is 2-3 months;
bipolar II patients tend to have shorter and less severe
episodes.
• Long-term course
• Most will have more than one episode
• Length of intervals between episodes varies and is
difficult to predict
• 40-50% of patients are able to achieve a sustained
recovery; rapid cycling patients have a worse
prognosis
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Etiology: Social Factors
& Depression
• Loss and depression
• significant others
• social role
• self-esteem
• Relationships and depression
• Social support (or lack of) and depression
Etiology: Mood Disorders
& Life Events
• Stressful life events and mood
disorders:
causality can go both ways…
• Severely stressful life often
precede the development of
mood disorders and relapse
• Stressful life events may be
generated by those with mood
disorders
Etiology: Learned Helplessness Theory
Seligman (1965)
• Learned Helplessness
passive behavior in the face of
negative situations
• Uncontrollable negative events
 learned helplessness
• Learned helplessness
 depression
But model does not explain why some become
depressed and others do not!
Reformulated Learned Helplessness Theory
(Abramson, Seligman, & Teasdale, 1978)
•
Uncontrollable event
•
Belief that what happens is uncontrollable
•
Depressogenic Attributional Style
Attribute negative event to stable, global,
and internal factors
•
Expectation of future uncontrollable events
•
Symptoms of helplessness and depression
Why is this important?
• These biases act as a lens through which people
view and interpret the world
• A schema is an expectation for how things
work in the world
• A depressive schema is a risk factor to
depression in the face of “failure” events
• Beck’s Cognitive Triad: Negative thoughts
about the self, the world, and the future
Etiology: Biological Factors
• Genetics
Family studies and twin studies suggest a mild
genetic influence for unipolar depression and a
stronger one for bipolar disorder
• Unipolar depression concordance rates:
MZ = .54, DZ = .24
• Bipolar disorder concordance rates:
MZ = .43, DZ = .06
• No strong evidence of a single gene responsible for
mood disorders.
Etiology: Stress-Gene Interactions
• We know that stress leads to depression in some
people, but not others.
Why?
• Could genes have something to do with it?
• Behavioral genetics suggest that they do, but we
would like to be able to support this with actual
genes!
Etiology: Stress-Gene Interactions
(Caspi et al., 2003)
• Prospective-longitudinal study with a
representative sample of 1037 people
• Level of genetic risk based on the serotonin
transporter gene:
2 short alleles (ss) = highest genetic
vulnerability (low serotonin level)
2 long alleles (SS) = lowest genetic vulnerability
(high serotonin level)
Serotonin is a neurotransmitter that is associated with
depression. Simply, more serotonin=less depression
Etiology: Stress-Gene Interactions
(Caspi et al., 2003)
• The effect of life events on depression symptoms
at age 26 was significantly stronger among those
with the genetic vulnerability
• Stressful life events predicted major depressive
disorder as well as suicidal ideation/attempts
only among those with the genetic vulnerability
Etiology: Stress-Gene Interaction
(Caspi et al., 2003)
Major Depressive Episode
MDE
...
0.5
0.4
0.3
0.2
0.1
0
0
1
2
3
number of stressful life events
high genetic
ss
medium genetic
sS
4+
low genetic
SS
Etiology: Neurotransmitters
• Early theories emphasizing the inability to utilize
serotonin and norepinephrine were probably overly
simplistic.
• Recent theories focus more on the interaction
between neurotransmitters and the sensitivity and
density of postsynaptic receptors.
• Current theories emphasize the interaction between
neurotransmitter systems including serotonin,
norepinephrine, dopamine and neuropeptides.
Mood Disorders
• Basic definitions
• Unipolar mood disorders
• Special topic: Depression & interpersonal
relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment
Interventions for Unipolar Disorders:
Cognitive Therapy
Beck’s approach focuses on:
• recognizing, challenging and overcoming
cognitive distortions and errors in logic
• replacing self-defeating cognitions with
more rational self-statements.
Cognitive Distortions
Event  Cognitive Distortions  Emotions
• Event
Getting a B on a quiz
• Thought (Cognitive Distortion)
“I’m a failure” (labeling)
“I’m going to fail the class” (all-or-nothing thinking)
• Emotion
sadness, disappointment, etc.
• Thought (Cognitive Restructuring)
“I have never failed a class before” (base rate)
• Emotion
decrease in sadness
Interventions for Unipolar Disorders:
Interpersonal Therapy (IPT)
Focuses on:
• interpersonal factors in current relationships
that cause and maintain depression building
• communication and problem-solving skills
• Four Areas
• Grief
• Role dispute
• Role transition
• Interpersonal deficits
Interventions for Unipolar Depression:
Effectiveness
Effectiveness of psychotherapy vs. antidepressants:
the Treatment of Depression Collaborative Research
Program (TDCRP) findings
• Cognitive, interpersonal therapy, and an
antidepressant (imiprimine) were all superior to
placebo plus clinical management condition for a 16week treatment.
• No significant differences emerged between the
effectiveness of the three treatment conditions.
Effectiveness continued: TDCRP
• Drug treatment led to a more rapid improvement
initially, although effects were equivalent over the
16 weeks.
• Type of improvement was independent of type of
treatment (e.g., medication changed cognitions just
as much as cognitive therapy).
Components of Psychotherapy for
Bipolar Disorder
• Medication compliance
• Psychoeducation: family or individual
• Regulating sleep, work and socialization
• Identifying and reducing triggers such as stress,
interpersonal conflict and substance use
• Symptom monitoring and relapse prevention
Suicide – Not Covered in Class
• But you do need to know the chapter, especially:
• Rates of suicide by age and gender
• Why people commit suicide
• The effectiveness of various intervention
programs
• You do not need to know Durkheim’s typology
Optional Slides
Mood Disorders
Clarifications
• Remission
• Partial: 2 months with some symptoms but not
meeting criteria
• Full: 2 months without any symptoms
• For episodes to be considered separate, a
remission period of at least 2 months has to occur.
• Specifier
• Chronic: meeting criteria for MDE for 2 years
• Single episode: Just one episode of depression in a
lifetime
• Recurrent: two or more episodes in a lifetime
Recurrent
Absence or Presence
• Two or more episodes
JAN
FEB
MAR
APR
MAY
JUN
JUL
month
Depressed
AUG
SEP
OCT
NOV
DEC
Chronic
Presence or Absence
One Continuous Episode for at least 2 years
1
2
3
4
5
6
7
8
9
10
weeks
major depressive episode
11
...
109 110
Seeking Help
• Only about 30% of those diagnosed as suffering
from a mood disorder made contact with a mental
health professional within 6 months prior to the
diagnostic interview.
• Alternatives: General practitioners, religious
leaders, and books.
• Social Stigma
• Problems with access: information, resources
Intervention for Unipolar Disorders:
Behavioral Activation
• Highlight the connection between the context
and the impact of behaviors on mood
• Increase pleasant activities
• Increase mastery activities
• Reduce avoidance behaviors
What are the two key symptoms that are
present in dysthymia but not major depression?
A. anhedonia and irritable mood
B. feelings of hopelessness and low selfesteem
C. increase in goal oriented activities and
flight of ideas
D. depressed mood and suicidal ideation
When a person’s symptoms are diminished or
improved, the disorder is considered to be in
A. relapse
B. remission
C. recovery
D. recycle
Rates of “successful” suicide are highest among
A. women
B. teenagers
C. the elderly
D. college students
What are the two key symptoms that are
present in dysthymia but not major depression?
A. anhedonia and irritable mood
B. feelings of hopelessness and low selfesteem
C. increase in goal oriented activities and
flight of ideas
D. depressed mood and suicidal ideation
Jack is worried about his friend Patrick. When asked, Patrick
says that he is feeling fine – just as good as ever. But Jack
doesn’t quite believe him. Even though Patrick says he feels
fine, Jack thinks he often looks a little bit sad. Even his body
seems a little slumped over.
Which of the following terms best describes Jack’s source of
information about how Patrick feels?
• A. Observer report
• B. Mood
• C. Affect
• D. Emotion
Correct Answer = C
• E. Self-report
What is Affect? How is it different
from Mood and Emotion?
Some researchers have suggested that all people
have basic needs, including a need to belong. It
might be further suggested that this need is part of the
reason why lacking an adequate social support
network can put a person at greater risk of suicide.
The need to belong is an example of a factor,
related to suicide.
• A. Social
• B. Psychological
• C. Biological
Correct Answer = B
Why? What are examples
of Social and Biological
factors that are mentioned
in your book?
http://www.youtube.com/watch?v=tZIvgQ9ik48
Which one does not belong as a symptom of
dysthymia?
• A. Insomnia or Hypersomnia
• B. Feelings of Hopelessness
• C. Poor Concentration/Decision-Making
• D. Feelings of Worthlessness
• E. Low Self-Esteem
Correct Answer = D
Which of the them are
more defining features of
dysthymia?
Which of the following is not a feature of
bipolar I disorder?
• A. Has lasted at least two years
• B. Elevated/euphoric mood
• C. Racing thoughts
• D. Psychomotor agitation
• E. At least one manic episode
Correct Answer = A
What disorders are marked by this
“at least 2 years” feature?
During adolescence, males are three times more
likely to attempt suicide than are females.
• A. True
• B. False
Correct answer = False.
Why? What do we know
about gender differences in
suicide?
Which of the following is not one of the
recommendations for what to do when working with
a client who is suicidal?
• A. Reduce lethality
• B. Negotiate agreements
• C. Provide support
• D. Create a broader perspective
• E. Hospitalize first
Correct Answer = E
What do the other four
options mean?
One type of depression is marked particularly by
somatic symptoms (e.g. overeating, craving carbs,
gaining weight, etc.) The specifier used for this
type of depression is:
• A. Melancholia
• B. Seasonal Affective
• C. with Psychotic Features
• D. Binging
• E. Postpartum
Correct Answer = B
What is a distinguishing feature
of these other specifiers?
Rates of “successful” suicide are highest among:
• A. Women
• B. Teenagers
• C. Elderly
• D. College Students
• E. Men
Correct Answer = C
What other demographic
features of these elderly
individuals are relevant to
suicide?