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Mood Disorders
PSYC4080 6.0D
Depression, Bipolar Disorder
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Mood Disorders
 Refer to a number of disorders where the patient
displays an “extreme” mood state
• Positive: Excitement, elation
• Negative: Sadness, emptiness
 Complex etiology: Most patients are believed to
have genetic predisposition
 Not necessarily triggered by a stressful event
 Extremely common, considered a major world
health issue (WHO, 2006)
 Among the most treatable mental health
disorders
PSYC4080 6.0D
Depression, Bipolar Disorder
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Prevalence of Mood Disorders
 Many people who suffer clinical depression do not
seek treatment
• Cultural, gender differences
 CAMH (Toronto) rates range from 10-25% of the
population seeking treatment
 Bipolar disorder is equally common in males and
females
 Major depression twice common in females
• Women also more likely to seek treatment.
PSYC4080 6.0D
Depression, Bipolar Disorder
3
Depression: Case Study
 A very capable professional woman in her mid-30s
became depressed as a consequence of difficulties in
conceiving a child. The couple had delayed trying to
have children, and desperately desired to become
parents. The difficulty in conceiving, and consequent
involvement in an IVF program, also led to significant
marital stress.
 The patient had started to cry frequently and had some
suicidal thoughts (although she had no intent to act upon
them). She had little energy and was easily fatigued -- in
contrast to her usual active and productive self.
PSYC4080 6.0D
Depression, Bipolar Disorder
4
Depression: Case Study
 She developed insomnia, her concentration was
impaired, and she lost her appetite. At times she would
shop and spend more than usual in order to cheer
herself up.She was referred to a counsellor for both
individual and marital therapy.
 The individual counseling focused upon the issues of her
grief over not being able to bear children, her guilt about
not attempting to conceive earlier, and the tension within
the marriage. However, despite skilled therapy for an
adequate time, her symptoms persisted.
PSYC4080 6.0D
Depression, Bipolar Disorder
5
Major Depressive Episode
A.



Five or more of the following symptoms that:
present during the same 2-week period
change from previous functioning
at least one of the symptoms is either (1)
depressed mood or (2) loss of pleasure.
(1) depressed mood most of the day, nearly
every day, as indicated by either subjective
report (e.g. feels sad or empty) or
observation made by others (e.g. appears
tearful).
 Children or adolescents – irritability
PSYC4080 6.0D
Depression, Bipolar Disorder
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Major Depressive Episode
(2) markedly diminished interest or pleasure in
all, or almost all, activities most of the day,
nearly every day (self-report or anecdote)
(3) significant weight loss when not dieting or
weight gain, or decrease or increase in
appetite nearly every day
 children – failure to meet weight milestones
PSYC4080 6.0D
Depression, Bipolar Disorder
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Major Depressive Episode
(4) insomnia or hypersomnia nearly every
day
(5) psychomotor agitation or retardation
nearly every day (observable by others,
not only through self-report)
(6) fatigue or loss of energy nearly every
day
PSYC4080 6.0D
Depression, Bipolar Disorder
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Major Depressive Episode
(7) Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day
(8) Diminished ability to think or concentrate, or
indecisiveness, nearly every day (self-report or
anecdote)
(9) Recurrent thoughts of death, recurrent suicidal
ideation (without a specific plan), or a suicide attempt
or a specific plan for committing suicide
B. The symptoms do not meet criteria for a mixed
episode (I.e. in one day, rapid alternation between mania
and depression)
PSYC4080 6.0D
Depression, Bipolar Disorder
9
Major Depressive Episode
C. Symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
D. The symptoms are not due to the direct physiological
effects of a substance, or a general medical condition.
E. The symptoms are not better accounted for by
bereavement, i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are
characterized by marked functional impairment.
PSYC4080 6.0D
Depression, Bipolar Disorder
10
Depressive Disorder
Major Depressive Disorder
 Presence of a single MDE that is chronic (2 months)
 Recurring MDE episodes
Dysthymia
 not meeting full criteria
 relatively intact functional capacity (need 2 months
duration)
 Specifiers: Postpartum onset, With seasonal pattern
(Seasonal Affective Disorder)
 Some features may be unusual (agitation, delusions,
catatonia)
PSYC4080 6.0D
Depression, Bipolar Disorder
11
Bipolar Disorder
 Much lower prevalence: 1-2%
 Atypical prior to age 12
 Initially may characterize as cyclothymia:
alternations between elevated and depressed
mood, without extreme effects on daily
functioning.
• May or may not progress to bipolar disorder
• Characterized by clinical depression (MDE) with
alternating manic or hypomanic episodes (elevated
mood, either extreme behaviour or not, respectively)
PSYC4080 6.0D
Depression, Bipolar Disorder
12
Case Study
 “Kevin”, a 28 year-old accountant, recently
separated from his wife of 6 years and was
apparently devastated by the breakup. His
friends at work described him as “extremely
moody” after his wife left him.
 According to other people present, at the
company Christmas party a few weeks later,
Kevin was having a casual yet involved discussion
with some of his colleagues regarding dating and
sexual prowess.
PSYC4080 6.0D
Depression, Bipolar Disorder
13
Case Study
 With little warning, Kevin began bragging about how he had
slept with hundreds of women, and about the size of his
penis. He then began ridiculing the other males in the
crowd at how small their penises must be for not having
slept with as many women as him.
 After some minutes of this screaming and taunting
behaviour, Kevin challenged the other males in the group to
pull their pants down to “see what they were made of”. He
then took off his own clothes, jumped onto a nearby table
and started masturbating, screaming unintelligibly.
 Kevin was restrained by security shortly thereafter. A brief
hospitalization and eventual psychiatric assessment
confirmed that Kevin had experienced a Manic Episode.
PSYC4080 6.0D
Depression, Bipolar Disorder
14
DSM-IV: Manic Episode
A. A distinct period of abnormally and persistently elevated,
expansive or irritable mood, lasting at least 1 week (or any
duration if hospitalization is necessary)
B. During the period of mood disturbance, 3 or more of the
following symptoms have persisted (4 if mood is irritable)
and have been present to a significant degree:
1) inflated self esteem or grandiosity
2) decreased need for sleep (e.g. feels rested after only 3
hours of sleep)
3) more talkative than usual or pressure to keep talking
PSYC4080 6.0D
Depression, Bipolar Disorder
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DSM-IV: Manic Episode
4) flight of ideas, or subjective experience that
thoughts are racing
5) distractibility
6) increase in goal-directed activity (work,
school, or sexually) or psychomotor agitation
7) excessive involvement in pleasurable
activities that have a high potential for painful
consequences
 unrestrained buying sprees, sexual
indiscretions, or foolish business investments
PSYC4080 6.0D
Depression, Bipolar Disorder
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DSM-IV: Manic Episode
C. The symptoms do not meet criteria for a Mixed
Episode
D. The mood disturbance is sufficiently severe to
cause marked impairment in occupational
functioning or in usual social activities or
relationships with others, or to necessitate
hospitalization to prevent harm to self or others,
or there are psychotic features.
PSYC4080 6.0D
Depression, Bipolar Disorder
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DSM-IV: Manic Episode
E. The symptoms are not accounted for by use of a
substance or medical condition.
 Hypomania: If symptoms persist for only 4
days, and episodes do not affect everyday
functioning.
PSYC4080 6.0D
Depression, Bipolar Disorder
18
DSM-IV: Bipolar Disorder
Bipolar I Disorder, Single Manic Episode
A. Presence of only one Manic Episode and no past
MDEs (could have dysthymia)
B. The Manic Episode is not better accounted for by
Schizoaffective disorder, and is not superimposed
on other psychotic disorders.
PSYC4080 6.0D
Depression, Bipolar Disorder
19
DSM-IV: Bipolar Disorder
Bipolar I Disorder, Most Recent Episode Hypomanic
A. Currently or most recently in a Hypomanic
Episode
B. There has previously been at least one Manic
Episode or Mixed Episode.
C. The mood symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
D. The mood episodes are not better accounted for
by Schizoaffective disorder, and is not
superimposed on other psychotic disorders.
PSYC4080 6.0D
Depression, Bipolar Disorder
20
DSM-IV: Bipolar Disorder
 Other subtypes:
•
•
•
•
Bipolar
Bipolar
Bipolar
Bipolar
I Disorder, Most Recent Episode Manic
I Disorder, Most Recent Episode Mixed
1 Disorder, Most Recent Episode Depressed
II Disorder – no Mania or Mixed episodes
 In all above cases, Major Depression must be
present.
PSYC4080 6.0D
Depression, Bipolar Disorder
21
Etiology of Mood Disorders
 Note that most studies are done on patients
with years of depression or bipolar disorder
 Begs the question of which came first, the
brain abnormalities or the depression.
 Assumption is mood disorders are biological
because they respond to treatment.
PSYC4080 6.0D
Depression, Bipolar Disorder
22
Etiology of Mood Disorders
 Ignores negative thought patterns that can maintain
depressive symptomatology – people with mood
disorders have been shown to think differently about
themselves, others, and the world (Segal, 2004)
 Common nature of depression argues against
biological cause
 Is depression adaptive?
PSYC4080 6.0D
Depression, Bipolar Disorder
23
Neuropathology: Depression
 Monoamine hypothesis: depression is caused
by insufficient activity of monoamines (NE and 5HT)
 Depression does not respond to DA agonists
 Lowering of NE and 5-HT metabolism in
depressed patients has been shown in PET
studies (Bremner et al., 1997; Smith et al.,
1999).
 Substance P (peptide) shown to increase DA
levels
• ventral tegmental area and prefrontal cortex and
alleviate symptoms of depression (Kramer et al., 1998;
Lejeune et al., 2002).
PSYC4080 6.0D
Depression, Bipolar Disorder
24
Neuropathology: Depression
 Overactivity of the beta-adrenoreceptor
• G protein-coupled receptor involved in the synthesis of
second messengers or ion channels
• These receptors are desensitized by 5HT and NE
The effects of NE and 5HT on this receptor is
likely related to the delayed mood altering
response of anti-depressants
PSYC4080 6.0D
Depression, Bipolar Disorder
25
Neuropathology
 Depression is associated with decreased volume
of the prefrontal cortex, basal ganglia, amygdala
and cerebellum (Soares and Mann, 1997;
Drevets, 2001)
 Bipolar disorder is associated with decreased
volume of the cerebellum and temporal lobes
(Soares and Mann, 1997) and increased volume
of the ventricles (Strakowski et al., 2002).
PSYC4080 6.0D
Depression, Bipolar Disorder
26
Neuropathology
 Seasonal pattern for depression:
• Winter – cravings for carbohydrates and weight gain;
oversleep (may be treated with phototherapy in early
morning 4:30 a.m. to 6 a.m. seem to be peak times)
• Summer – sleep less, lose appetite, and lose weight
PSYC4080 6.0D
Depression, Bipolar Disorder
27
Other Information
Suicide Rate in Canada (StatsCan, 1997)
 Males: 19.6/100000
 Females: 5.1/100000
 Number of suicides have quadrupled since 1960,
but have remained stable over the last 20 years.
 Rates are fairly steady over the lifespan (15+
years of age), but it is rising in young
adolescents and children
 A leading cause of death during adolescence
PSYC4080 6.0D
Depression, Bipolar Disorder
28