Mood disorders

Cortisol

- A hormone released as a stress response

Two types of Bipolar

- Bipolar I - Bipolar II - require the presence of a major depressive episode; can occur before or after the manic/hypomanic episode, will alternate or "cycle" throughout ones life

Efficacy of treatment options for bipolar disorders

- Lithium and other mood stabilizers are very effective in managing symptoms of patients with bipolar disorder. - adherence to the medication regimen is often the issue. The euphoric highs that are associated with manic and hypomanic episodes are often desired by bipolar patients, thus often leading them to forgo their medication - Combination of psychopharmacology and psychotherapy aimed at increasing rate of adherence to medical treatment may be the most effective treatment option for bipolar I and II disorder

Two most common types of depressive disorders

- Major depressive disorder - persistent depressive disorder (Dysthymia)

Psychological treatment of bipolar

- Majority of psychological interventions are aimed at medication adherence, as many bipolar patients stop taking their mood stabilizers when they "feel better" - Social skills training and problem-solving skills are also helpful techniques to address in the therapeutic setting as individuals with bipolar disorder often struggle in this area

Endocrine system

- a collection of glands responsible for regulating hormones, metabolism, growth and development, sleep, and mood among other things. - cortisol has been implicated in the development of depression - melatonin may be related to depressive symptoms, particularly during winter months

Melatonin

- a hormone released when it is dark outside to assist with the transition to sleep

Treatment options for depressive disorder

- antidepressant medications - cognitive-behavioral therapy - behavioral activation - interpersonal therapy - treatment is generally dictated by therapist competence, availability, and patient preference

Physical

- changes in sleep patterns - excessive sleep or insomnia - change in weight or eating behaviors - psychomotor agitation or retardation, purposeless or slowed physical movement of the body (pacing around a room, tapping toes, restlessness)

Cognitive behavioral therapy (CBT)

- cognitive triad: cognitions (thoughts), behaviors, and emotions - Beck believed these three components are interconnected, and therefore, effect one another - believed CBT can improve emotions in depressed patients by changing both cognitions and behaviors, which in return will improve mood.

Multimodel treatment

- combination of pharmacological and psychological treatment may offer additional benefits - helpful for individuals who have not achieved wellness in a single modality - treatments can be done concurrently, treatments can be done sequentially, or treatments can be offered within stepped treatment

Automatic thoughts

- constant stream of negative thoughts lead to symptoms; begin to feel as inadequate or helpless in a given situation

What is an indicator that a manic episode is about to happen (imminently)?

- decreased need for sleep

Behavioral

- decreased physical activity and reduce productivity - typically where a disruption in daily functioning is observed as individuals with depressive disorders are unable to maintain their social interactions and employments responsibilities

Family-social perspective

- depression is related to the unavailability of social support - separated and divorced individuals are 3x more likely to experience depressive symptoms than those that are married or widowed - depressive symptoms have been positively related to increased interpersonal conflicts, reduced communication, and intimacy issues, all of which are often reported in causal factors leading to a divorce

depression at a molecular level

- depression may be tied to the 5-HTT gene on chromosome 17, as this is responsible for the activity of serotonin

Describe the biological causes of mood disorders

- depressive disorder have some biological cause - does not explain every case, but safe to say some individuals may at least have a predisposition to develop a depressive disorder - among biological factors are genetic factors, biochemical factors and brain structures

Interpersonal therapy

- depressive episodes compromise interpersonal functioning, which in return, makes it difficult to manage stressful life events. - The basic mechanism of IPT is to establish effective strategies to manage interpersonal issues, which in return, will ameliorate depressive symptoms. Two main principles: - depression is a common, medical illness which is treatable and not the patient's fault - depression is connected to a current or recent life event. Goal is to identify and solve the crisis

Key differences between depressive disorder and bipolar

- depressive only experience symptoms of depression -bipolar have periods of mania/hypomania that alternate with periods of depression

Describe the behavioral causes of mood disorders

- explains depression as a result of change in the number of rewards and punishments one receives throughout their life (work, intimate relationships, family, or even the environment in general - Peter Lewinsohn stated depression occurred in most people due to the reduced positive rewards in their life, leading to constructive behaviors occurring more infrequently until they stop engaging in the behavior completely

Rumination (deep thought) theory

- fifth theory - suggests that women are more likely than men to ruminate, or intently focus, on their depressive symptoms, thus making them more vulnerable to developing depression at a clinical level - several studies have supported this theory and shown that rumination of negative thoughts is positively related to an increase depression symptoms

Artifact Theory

- first theory - difference between genders is due to clinician or diagnostic systems being more sensitive to diagnosing women with depression than men - women are more sensitive, emotional than men but research has failed to support

Positive Attributional style

- focuses on the external, unstable, and specific influence of the environment

Negative attributional style

- focuses on the internal, stable, and global influence of daily lives - more likely to experience depression due to their negative interpretation of daily events - precursor to depressive disorders EX: if something bad were to happen to them, they conclude that it is *their* fault (internal), bad things *always* happen to them (stable), and bad things happen *all* day to them. This maladaptive thinking style takes over daily view

Gender roles theory

- fourth theory - social and or psychological factors related to traditional gender roles also influence the rate of depression in women EX: men are encouraged to develop personal autonomy, seek out activities that interest them, and display achievement oriented goals, women are encouraged to empathize and care for others, often fostering an interdependent functioning, which may cause women to value the opinion of others more likely than their male counterparts do.

Behavioral activation (BA)

- goal is to alleviate depression and prevent future relapse by changing an individual's behavior - minimize negative behavior and maximize pleasurable activities, in order to receive more positive rewards or reinforcement from others and their environments

Comorbidity of bipolar disorder

- high Comorbidity rate with other mental disorders, particularly anxiety disorders and any other disruptive/impulse-control disorder such as ADHD and conduct disorder - substance abuse is common; over half of those with bipolar meet criteria for substance (alcohol) abuse - combining bipolar and substance abuse place individuals at a greater risk of suicide attempts - Bipolar II has more Comorbidity, 60% meet criteria for 3 or more co-occurring mental disorders

Genetics

- if there is a genetic predisposition to developing depressive disorders, one would expect a higher rate of depression within families than that of the general population - 30% increase in relatives diagnosed with depression, compared to 10 percent of the general population - elevated prevalence among first-degree relatives for both bipolar I and bipolar II

Maladaptive attitudes

- individuals with depressive symptoms often develop these maladaptive attitudes regarding everything in their life, indirectly isolating themselves from others - The cognitive triad also plays into maladaptive attitudes in that the individual interprets these negative thoughts about their experiences, themselves, and their futures

Errors in thinking (cognitive distortions)

- key component in Beck's cognitive theory - 15 errors in thinking that are most common in individuals with depression: catastrophizing, jumping to conclusions, and overgeneralizations (this *always* happens, but does it *always* happen?)

Manic episode

- key feature is a specific period of time in which an individual experiences abnormally, persistently, expansive or irritable mood for nearly all day, every day, for at least one week

Describe the cognitive causes of mood disorders

- learned helplessness is often equated with depression - cognitive strategies are among the most effective forms of treatment for depressive disorders

Four category symptoms of depression

- mood - behavioral - cognitive - physical

Psychopharmacology Treatment options for bipolar

- mood stabilizers such as Lithium or Depakote do not induce mania. Combined with antidepressants later in treatment *only* if absolutely necessary - antidepressants are often known to trigger a manic or hypomanic episode in Bipolar patients, because of this, the first line treatment option for Bipolar Disorder is mood stabilizers, particularly Lithium

Antidepressant medications

- most common first line attempt at treatment for MDD - "easier" treatment for depression as the individual can take the medication at their home rather than attending weekly therapy sessions but issues of not taking meds

Selective Serotonin Reuptake Inhibitors medication

- most common med due to benign side effects - required dose to reach therapeutic levels is low compared to other - Possible side effects include nausea, insomnia, and reduced sex drive - improve depression symptoms by blocking the reuptake of norepinephrine and/or serotonin in presynaptic neurons, thus allowing more of these neurotransmitters to be available for postsynaptic neuron. - minor biological diff among diff types of meds with SSRIs, which are actually beneficial to patients in that there are a few treatment options to maximize med benefits and minimize side effects

Genetic components of a disorder via twins

- nearly a 46% chance that if one identical twin was diagnosed with depression, that the other was as well. - fraternal twin rate was only 20% - genetics is a strong component of bipolar - identical twins within bipolar are as high as 72% - fraternal twins, siblings, and other close relatives are 5-15%

Cognitive

- negative view - quick to blame themselves - rarely take credit - worthless - difficulty concentrating on tasks, as they are easily distracted - perform worse on tasks of memory, attention, and reasoning - thoughts of suicide and self harm

Multi-cultural perspective: Latino and Mediterranean cultures

- often experience problems with "nerves" and headaches as primary symptoms of depression

Multi-cultural perspective: Non-Western countries (China and other Asian countries)

- often focus on the physical symptoms of depression- tiredness, weakness, sleep issues, and less of an emphasis on the cognitive symptoms

Multi-cultural perspective

- one's cultural background may influence *what* symptoms of depression are presented - In the US, researchers continually fail to identify any significant differences between ethnical and racial groups; however, one major study has identified a difference in the rate of recurrence of depression in Hispanic and African Americans~ lack of treatment opportunities may be possible explanation - approx. 54% of depressed whites seek treatment compared to 34% and 40% of hispanic and african americans

Four phases of treatment in cognitive behavioral therapy

- phase 1: increasing pleasurable activities~ encouraging patient to identify and engage in pleasurable activities - Phase 2: challenging automatic thoughts~ clinicians provides psychoeducation about neg automatic thoughts that can maintain depressive symptoms - Phase 3: identifying negative thoughts~ identify *how* these thoughts are maintaining their symptoms. The patient begins to have direct insight as to how their cognitions contribute to their disorder - Phase 4: changing thoughts~ challenging the negative thoughts the patient has been identifying in the last two phases of treatment and replacing with positive thoughts

Behavioral interventions o CBT

- planning, pleasant event scheduling, task assignments, and coping-skills training

Epidemiology of depressive disorders

- prevalence rate for mdd is 7% in US - PDD rate is much lower, with a 0.5% rate among adults in US -18-29 year old is highest rate of depression among any age group - 1.5-3x higher in females than males - estimated lifetime prevalence for mdd is women is 21.3% compared to 12.7% in men

Efficacy of treatment options for depressive disorder

- psychopharmacological interventions are more effective in rapidly reducing symptoms - psychotherapy or even a combination treatment approach are more effective in establishing long-term relief of symptoms

Mood lability

- rapid shifts in mood ranging from happy, neutral, to irritable

Mood

- reports of significant mood disturbances such as depressed - anhedonia: which is the loss of interest in previously interesting activities

Hormone theory

- second theory - variations in hormone levels trigger depression in women more than men - changes in hormone levels during phases of menstrual cycle and their impact on women's ability to integrate and process emotional info, research fails to support this theory

Family-social perspective~ opposite view

- stress and marital discord leading to increased rates of depression in one or both spouses - children may provide + influence, it can also lead to stress within individual and between partners due to division of work and discipline differences - research shows that women with 3 or more young children who lack a close confidante and outside employment, were more likely to become depressed

Biochemical

- strong evidence of biochemical deficit in depression and bipolar disorders - low activity levels of norepinephrine and serotonin contributing factors to developing depressive disorders - mania episodes may be explained by *low* levels of serotonin and *high* levels of norepinephrine

Cyclothymic disorder

- subclass of individuals who experience periods of hypomanic symptoms and mild depressive symptoms (do not fully meet criteria for depressive episode) - symptoms occur for two or more years, typically interrupted by periods of normal moods - only a small percentage of the population develop cyclothymic, but eventually may progress into bipolar I or bipolar II

Epidemiology of suicidality

- suicidality in bipolar is much higher than general public - individuals with bipolar are approx 15x greater than the general pop to attempt suicide - prevalence rate of bipolar individuals attempting are 33%, may account for one-quarter of all completed suicides

Describe the sociocultural causes of mood disorders

- the role of family and one's social environment play a strong role in depression - Two sociocultural views: the family-social perspective and the multi-cultural perspective

Life stress theory

- third theory - women are more likely to experience chronic stressors than men, thus accounting for their higher rate of depression - women are at an increased risk for facing poverty, lower employment opportunities, discrimination, and poorer quality of housing than men, all of which are strong predictors of depressive symptoms

Common cognitive interventions with CBT

- thought monitoring and recording, identifying cognitive errors, examining evidence supporting/negative cognitions, and creating rational alternatives to maladaptive thought patterns.

Gender differences

- women twice as likely to experience an episode of depression than men - no one single theory has produced enough evidence to fully explain why women experience depression more than men 5 theories: - artifact theory - hormone theory - life stress theory - gender roles - rumination theory

Epidemiology of bipolar disorder

- yearly rates reported as .6 and .8% in the US for bipolar I&II. - no gender differences in bipolar I - Bipolar II is more common in women, approx 80-90% of individuals with rapid-cycling episodes being women - women are also more likely to experience rapid cycling between manic/hypomanic episodes and depressive episodes

Comorbidity of depressive disorder

-substantial pattern of Comorbidity between depression and other mental disorders, particularly substance abuse - 3/4 of participant with lifetime mdd also meet criteria for at least one other DSM disorder - most common are anxiety disorder, ADHD, and substance abuse - most depression cases occur secondly to another mental health disorder meaning that the onset of depression is a direct result to the onset of another disorder

Major Depressive Disorder Diagnostic Criteria

1. Had one major depressive episode 2. Never had a manic or hypomanic episode

9 symptoms of major depressive episode

1. depressed mood most of the day 2. decreased interest or pleasure in all, or almost all, activities most of the day 3. Significant weight or appetite change (loss or gain) not due to dieting 4. Insomnia or hypersomnia 5. psychomotor agitation or retardation 6. fatigue or loss of energy 7. feelings or worthlessness 8. difficulty concentrating or indecisiveness 9. recurrent thoughts of death, suicidal ideation, or suicide attempt

Hypomanic Episode Diagnostic Criteria

A. Persistently elevated, expansive, or irritable mood. May present as persistent increased activity or energy. Symptoms *last at least 4 consecutive days* and present most of the day, nearly every day. B. In addition, at least 3 of the following symptoms (4 if the mood is only irritable): - Inflated self-esteem or grandiosity - Decreased need for sleep - More talkative or Pressured speech - Flight of ideas - Distractibility - Increase in goal-directed activity or psychomotor agitation - Excessive involvement in activities that have a high potential for painful consequences C. Change in behavior and mood are observable by others. D. Causes impairment is social or occupational functioning.

Major depressive episode

A. 5 or more symptoms present during the same 2-week period and represent a change from previous functioning; one symptoms is either (1) depressed mood or (2) loss of interest or pleasure B. Must cause significant distress or impairment in social, occupational, or other important areas of functioning

Bipolar II Disorder Diagnostic Criteria

A. Criteria been met for at least one *hypomanic episode* and at least one *major depressive episode* B. Never had a manic episode C. Symptoms are not better explained by a personality disorder D. Symptoms cause clinically significant distress or impairment in daily functioning

Bipolar I disorder diagnostic criteria

A. Criteria have been met for a least one manic episode B. Symptoms are not explained by a personality disorder

Persistent Depressive Disorder Diagnostic

A. Depressed mood for most of the day, for more days than not, for *at least 2 years* B. Two (or more of the following) - poor appetite or overeating - insomnia or hypersomnia - low energy or fatigue - low self-esteem - poor concentration or difficulty making decisions - feelings of hopelessness C. Never been without the symptoms in Criteria A and B for more than 2-months during 2-years of symptoms; Symptoms can be present during entire 2-years without a break D. *never* had a manic episode or a hypomanic episode

Manic Episode Diagnostic Criteria

A. Persistent elevated, expansive, or irritable mood. May present as persistent increased goal-directed activity or energy. Symptoms *last at least 1 week* and present most of the day, nearly every day B. At least 3 of following symptoms (4 if mood is irritable) - inflated self-esteem or grandiosity - decreased need for sleep - more talkative or pressured speech - flight of ideas - distractibility - increase in goal-directed activity or psychomotor agitation - excessive involvement in activities that have a high potential for painful consequences C. causes impairment is social or occupational functioning

Brain anatomy

All have been linked to depression - prefrontal cortex: drastic changes in blood flow - a smaller hippocampus and fewer number of neurons - amygdala~ flight or fight: heightened activity and blood flow Linked to bipolar: - basal ganglia and cerebellum are found to be smaller - decrease in brain activity in regions associated with regulating emotions, as well as increase in brain activity among structures related to emotional responsiveness