chapter 7- Bipolar and Depressive Disorders

Biological treatments for depressive disorder: therapies

Electroconvulsive therapy --Effective for those that not responding to medication or with severe depression Light therapy --Exposed to artificial light --For seasonal affective disorder (SAD) •Transcranial magnetic stimulation •Deep brain simulation -electrodes implanted in the brain --Possible surgical complications

which treatment is best for major depressive disorder?

interpersonal psychotherapy and CBT have strongest support •Medication may be more effective for severely depressed •60% respond to psychotherapeutic interventions, but relapse may occur

Bipolar I

involves full-blown mania with episodes of major depression

Bipolar disorder in adults (60 or older)

manic and depressive symptoms often develop in association with medical illness •Recurrence is more common in older adults

psychological treatment of depressive disorder

Cognitive-behavioral therapy (CBT) --Monitor thoughts, feelings, and behaviors Interpersonal psychotherapy (IPT) --Emphasizes current interpersonal relationships --Expression of mood, clarification of feelings, communication analysis, behavior change Behavioral activation -increase access to reinforcing events --Behavioral activation treatment for depression (BATD)

psychological treatment for bipolar disorder

Cognitive-behavioral therapy (CBT) •Change inappropriate or negative thought patterns and behavior Results of the effectiveness have been inconsistent Interpersonal and social rhythm therapy (IPSRT) •Adherence to regular daily routines •Interpersonal therapy with social zeitgeber hypothesis

Biological treatments for depressive disorder: first generation antidepressants

First-generation antidepressants -tricyclic antidepressants, and monoamine oxidase inhibitors •MAOIs prevent the breakdown of neurotransmitters •Tricyclic antidepressants prevent the reuptake of neurotransmitters such as norepinephrine and serotonin •Less effective in children and adolescents

Biological treatment for bipolar disorder

Lithium most commonly used medication --Modulates glutamate levels --Intended as long-term therapy Anticonvulsant medications in combination with lithium Electroconvulsive therapy (ECT) --Used when medication and psychotherapy are ineffective, in high suicide risk, or when medication is contraindicated

cognitive theory

Psychologist Beck - negative cognitive schemas (negative thoughts) •Automatic (involuntary) thoughts •Self-fulfilling prophecies (believing something might happen and so it happens) •Negative cognitive triad -negative thoughts about the self, the world, and the future

Biological treatments for depressive disorder: second generation antidepressants

Second-generation antidepressants •Selective serotonin reuptake inhibitors (SSRIs) •Fewer and milder side effects than first-generation tricyclic antidepressants •Evidence for increased risk of suicidal thinking in children and adolescents

Hypomania

may be overly talkative, excitable, or irritable, but there is no impulsive acts or gross lapses of judgment •lasts at least 4 days

which treatment is best for bipolar disorder?

medication with lithium or anticonvulsants is most common •Psychotherapy alone is not effective

primary treatment of bipolar disorder

medications

risk factors for suicide

•Family history •Psychiatric illness --Approximately 90% of those that attempt suicides or die by suicide suffer from psychological disorders --70% of those that attempt had a mood disorder in the past 12 months --Other disorders marked by anxiety, agitation, and impulse control problems •Biological factors --Serotonergic system (nerve ending that releases and is stimulated by serotonin)

suicidal ideation

thoughts of death

depression disorder comorbidity

•About 72.1% of adults with lifetime major depressive disorder had at least one additional psychological disorder --Anxiety disorders (59.2%) --Substance use disorder (24%) --Impulse control disorders (30%) •Depression is the most common comorbid disorder in eating disorders

race and ethnicity differences of those who commit suicide

•American Indian/Alaskan Native (0.9%) •Hispanic (0.8%) •Non-Hispanic blacks (0.6%) •Whites (0.5%) •Asian (0.2%)

neuroimaging studies: parts of brain related to mental disorders

•Amygdala -memory and emotions •Orbitofrontal cortex -decision making •Dorsolateral prefrontal cortex -affect regulation, planning, and decision making •Anterior cingulate cortex -error detection, motivation, and modulation of emotional responses •Some neurological differences may be due to effects of treatment --Example: lithium may lead to small hippocampus and amygdala

Bipolar disorder comorbidity

•Bidirectional comorbidity •might be at risk for several medical conditions •Comorbid psychological conditions include anxiety disorders, behavioral disorders, and substance use disorders •May self-medication with drugs and alcohol

Persistent Depressive Disorder (Dysthymia)

•Chronic state of depression •Milder symptoms of major depressive disorder •Symptoms last 2 or more years, never without symptoms for more than 2 months •Double depression -Dysthymia with major depressive episodes •6.4% of the general population

explanation for sex differences for presence of depression

•Hormones •Bodily changes during puberty •Socioeconomic disadvantages •Victimization or chronic life stressors •Self-esteem •Higher reactivity to stress •Neuroticism

treatment for depressive disorder

•Important first step is a comprehensive physical exam •Only about half with major depressive depression obtain professional treatment; of these only 22% receive clinically adequate care

prevalence, age of onset, comorbidity, sex, race

•In North American, lifetime prevalence of bipolar I is .09% to 1.0% and bipolar II is 0.6% to 1.1% •Age of onset is 18.4 years for bipolar I and 20.0 for bipolar II •No differences by sex, race/ethnicity, or family income level •Commonly comorbid with substance use disorders, anxiety disorders, and impulse control disorder •Bipolar I more common in men, bipolar II more common in women •White more likely to be diagnosed with bipolar whereas African Americans more likely to receive a diagnosis of schizophrenia spectrum

who commits suicide?

•In the United States, 3.9% of adults reported suicide ideation within the past year --1.1% reported making suicide plans --0.6% reported suicide attempts •Males were slightly more likely to attempt suicide •Females were more likely to report suicidal ideation •In adolescents, risk factors include major depressive and bipolar disorder, previous suicide attempts, substance abuse, conduct disorder, and presence of a gun in the home --Drifting -being disconnected from school, work, and family •Immediate events: relationship breakdown, interpersonal problems, financial difficulties •One-third of those that attempt do not identify a specific factor •Among older adults, chronic illness and decreasing social support may increase risk

prevention of suicide

•Intervention must focus on prevention •Crisis intervention such as suicide hotlines •Focus on high-risk groups such as those with mood disorders and previous attempts •Societal level prevention •Preventing suicidal contagion --Critical incidence debriefing (CID)-intervention for witnesses after a youth commits suicide

environmental factors and life events in relation to mental disorders

•Major depressive disorders may be associated with stress, loss, grief, treats to relationships, occupational problems, and health challenges •Teasing apart the relationships between stressful life events and mood disorders is difficult •Genetic control of sensitivity to the environment •Two people can encounter the same stressful life event but experience it differently

Depressive disorders related to reproductive events: premenstrual dysphoric disorder (PMDD)

•Mood symptoms vary from deep sadness or despair, anxiety and tension, anger or irritability, and panic •Changes in sleep, appetite, and libido may also occur •Prevalence: 1.3% to 4.6% of women of reproductive age

ethics and responsibility regarding suicide

•More than 90% of children who commit suicide have a psychological disorder •Suicide ideation and attempts are higher in children and adolescents with anxiety disorder, eating disorder, oppositional defiant disorder, and ADHD •Parents and teachers are cautioned not to ignore warning signs --Work to prevent copycat suicide attempts --Avoid glamorizing suicide

genetic factors for MDD and generalized anxiety disorder

The same genetic factors may influence both •Environment may shape the development of these disorders

Cyclothymic disorder

fluctuations that alternate between hypomanic and depressive symptoms •Symptoms not as severe as with full mania or major depression •Persists for at least 2 years •Unpredictable mood changes

Bipolar disorder

formally known as manic-depressive disorder •Both episodic depressed mood and episodic mania are present •Dramatic shifts in mood, energy, and ability to function •During depressed period -all but immobile •During manic period -full of energy •At either extreme, the person has difficulty coping with the demands of everyday life

Rapid cycling bipolar disorder

four or more severe mood disturbances within a single year

Bipolar disorder in children

rate has increased over time symptoms are different compared to adults •mania may be chronic rather than episodic, may cycle rapidly, and appear as a mixed state •more likely to display irritability and temper tantrums •May be difficult to distinguish symptoms from other conditions such as ADHD, conduct disorder, oppositional defiant disorder, and schizophrenia •Intervals (time between) between mania and depression are shorter and episodes longer in younger patients

passive suicidal ideation

wish to be dead without active planning

Disruptive mood dysregulation disorder

•New disorder for the DSM-5 •For children ages 6-18 •"Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation" •One argument for DMDD is to lower the rate of children diagnosed with bipolar disorder •Arguments against: --Most children who are diagnosed already meet the criteria for other childhood disorders --Poor reliability among clinicians --Temper tantrums may turn into a mental illness

major depressive disorder

•Persistent sad or low mood •In children, mood disturbance may manifest as irritability or hostility •Depressed mood can lead to psychological, emotional, social,and physical problems •Atypical (not representative of a type, group, or class) depression --Example: sleeping and eating more than usual •Considered an episodic illness --Approximately 16.2% of adults suffer from at least one episode in their lifetime and 6.6% over the last 12 months --A single episode lasts at least 2 weeks •Symptoms must affect the person's ability to function in social and work settings •most common disorder in the United States with lifetime prevalence of 16.2% to 19.2% in adults over 18

Treatment after suicide attempts

•Prolonged psychological care beyond the effects of the attempt are often necessary •Various interventions reduce self-harm behavior and improve mood, but impact on reducing subsequent suicide is unclear •Many who attempt suicide do not receive proper psychotherapeutic attention afterward

understanding death by suicide

•Psychological autopsy -Between one-fifth to one-third leave suicide notes ---Typically do not leave details on what led to the act -Clinical interviews aim to address potential precipitants and stressor, motivation, lethality, and intentionality •Those left behind search for clues and often blame themselves for not noticing

Suicide

•Suicide is the 10th leading cause of death in the United States and 15th worldwide •Across the world, 75% of suicides occur in low- and middle-income countries •Highest male suicide rates are found in Guyana and Lithuania, with rates greater than 50 per 100,000

behavioral theories

•Withdrawal of reinforcement for healthy behavior •Learning and modeling -Learned helplessness --External uncontrollable environments and internal uncontrollable environments are inescapable

active suicidal ideation

includes details on how to commit the act

psychodynamic theory

explains depression as "anger turned inward" •After a real or imagined loss •Melancholia •Depression and mania are interlinked -mania is a defense against unwanted or intolerable depression

Bipolar II

hypomania or "mild mania," with episodes of major depression •More common than bipolar I •at least one episode of major depression and at least one hypomanic event

Mania

mental illness marked by periods of great excitement or euphoria, delusions, and overactivity. is clearly excessive and is often accompanied by inappropriate and potentially dangerous behavior, irritability, pressured or rapid speech, and a false sense of well being. different from elated mood