Chapter 7

Major Depressive Disorder: An Overview

Clinical features ▪ One or more major depressive episodes separated by periods of remission ▪ Single episode - highly unusual ▪ Recurrent episodes - more common If two or more major depressive episodes occurred and were separated by at least 2 months during which the individual was not depressed, the major depressive disorder is noted as being recurrent. Recurrence is important in predicting the future course of the disorder, as well as in choosing appropriate treatments. From 35% to 85% of people with single-episode occurrences of major depressive disorder later experience a second episode Because of this finding and others reviewed later, clinical scientists have recently concluded that unipolar depression is often a chronic condition that waxes and wanes over time but seldom disappears (Judd, 2012). The median lifetime number of major depressive episodes is 4 to 7; in one large sample, 25% experienced six or more episodes (Angst, 2009; Kessler & Wang, 2009). The median duration of recurrent major depressive episodes is 4 to 5 months

Depressive Attributional Style

Internal attributions ▪ Negative outcomes are one's own fault • Stable attributions ▪ Believing future negative outcomes will be one's fault • Global attribution ▪ Believing negative events will disrupt many life activities • All three domains contribute to a sense of hopelessness

Lithium

Lithium carbonate = a common salt • Treatment of choice for bipolar disorder • Considered a mood stabilizer because it treats depressive and manic symptoms • Toxic in large amounts ▪ Dose must be carefully monitored • Effective for 50% of patients • Why lithium works is partially understood

DSM-5 (Unipolar) Depressive Disorders

Major depressive disorder • Persistent depressive disorder • New to DSM-5: ▪ Premenstrual dysphoric disorder ▪ Disruptive mood dysregulation disorder

An Overview of Depression and Mania

Mood disorders = gross deviations in mood • Composed of different types of mood "episodes" ▪ Periods of depressed or elevated mood lasting days or weeks, including: • Major depressive episodes • Manic episodes • Hypomanic episodes Hypo= less or under Beginning with the third edition of the Diagnostic and Statistical Manual (DSM-III), published by the American Psychiatric Association in 1980, these problems have been grouped under the heading mood disorders because they are characterized by gross deviations in mood.

Mixed features specifier.

Predominantly depressive episodes that have several (at least three) symptoms of mania as described above would meet this specifier, which applies to major depressive episodes both within major depressive disorder and persistent depressive disorder.

Assessing Safety, Health and Well Being in Adults: Physical Well-Being

Sleep ▪ Diet ▪ Cognitive Changes ▪ Libido/Sexual Behavior ▪ Activity/Exercise ▪ Substance Use/Abuse/Dependence

Psychological Dimensions (Stress)

Stress is strongly related to mood disorders • Poorer response to treatment • Longer time before remission ▪ Context of life events matters ▪ Gene-environment correlation: People who are vulnerable to depression might be more likely to enter situations that will lead to stress ▪ The relationship between stress and bipolar is also strong Stress and trauma are among the most striking unique contributions to the etiology of all psychological disorders. This is reflected throughout psychopathology and is evident in the wide adoption of the diathesis-stress model of psychopathology presented in Chapter 2 (and referred to throughout this book), which describes possible genetic and psychological vulnerabilities. so most investigators have stopped simply asking patients whether something bad (or good) happened and have begun to look at the context of the event, as well as the meaning it has for the individual. One crucial issue is the bias inherent in remembering events. If you ask people who are currently depressed what happened when they first became depressed more than 5 years ago, you will probably get answers different from those that they would give if they were not currently depressed. Because current moods distort memories, many investigators have concluded that the only useful way to study stressful life events is to follow people prospectively, to determine more accurately the precise nature of events and their relation to subsequent psychopathology. Severe events precede all types of depression except, perhaps, for a small group of patients with melancholic or psychotic features who are experiencing subsequent episodes where depression emerges in the absence of life events (Brown et al., 1994). For example, childhood sexual abuse (in addition to a family history of depression and anxiety disorders) is a significant predictor of a first onset of depression in young adults (Klein et al., 2013). In addition, for people with recurrent depression, the clear occurrence of a severe life stress before or early in the latest episode predicts a poorer response to treatment and a longer time before remission (Monroe et al., 2009; Monroe, Kupfer, & Frank, 1992), as well as a greater likelihood of recurrence (Monroe et al., 2009; Monroe, Roberts, Kupfer, & Frank, 1996). Although the context and meaning are often more important than the exact nature of the event itself, there are some events that are particularly likely to lead to depression. One of them is the breakup of a relationship, which is difficult for both adolescents (Carter & Garber, 2011; Monroe, Rohde, Seeley, & Lewinsohn, 1999) and adults (Kendler, Hettema, Butera, Gardner, & Prescott, 2003). Kendler and colleagues (2003) demonstrated in an elegant twin study that if one twin experienced a loss, such as the death of a loved one, that twin was 10 times more likely to become depressed than the twin who didn't experience the loss. But if one twin is also humiliated by the loss, as when, for example, a boyfriend or husband leaves the twin for a best friend and the twin still sees them all the time, then that twin would be 20 times more likely to get depressed than a twin with the same genes who didn't experience the event. One example would be people who tend to seek difficult relationships because of genetically based personality characteristics that then lead to depression. Kendler and colleagues (1999a) report that about one third of the association between stressful life events and depression is not the usual arrangement where stress triggers depression but rather individuals vulnerable to depression who are placing themselves in high-risk stressful environments, such as difficult relationships or other risky situations where bad outcomes are common. Moreover, the relative importance of the contribution of genetic factors versus environmental effects seems to differ depending on age: Whereas heritability depression (and anxiety) symptoms is high during childhood, the importance of environmental effects increases with age (Nivard et al., 2015). First, typically negative stressful life events trigger depression, but a somewhat different, more positive, set of stressful life events seems to trigger mania (Alloy et al., 2012; Johnson et al., 2008). Specifically, experience associated with striving to achieve important goals, such as getting accepted into graduate school, obtaining a new job or promotion, getting married, or any goal striving activity for popularity or financial success trigger mania in vulnerable individuals (Alloy et al., 2012). Second, stress seems to initially trigger mania and depression, but as the disorder progresses, these episodes seem to develop a life of their own. Third, some precipitants of manic episodes seem related to loss of sleep, as in the postpartum period (Goodwin & Jamison, 2007; Harvey, 2008; Soreca et al., 2009) or as a result of jet lag—that is, disturbed circadian rhythms (Alloy, Nusslock, & Boland, 2015). In most cases of bipolar disorder, nevertheless, stressful life events are substantially indicated not only in provoking relapse but also in preventing recovery Finally, although almost everyone who develops a mood disorder has experienced a significant stressful event, most people who experience such events do not develop mood disorders.

Risk Factors

Suicide in the family ▪ Low serotonin levels ▪ Preexisting psychological disorder ▪ Alcohol use and abuse ▪ Stressful life event, especially humiliation ▪ Past suicidal behavior ▪ Plan and access to lethal methods Among the methods he and others have used to study those conditions and events that make a person vulnerable is psychological autopsy. The psychological profile of the person who committed suicide is reconstructed through extensive interviews with friends and family members who are likely to know what the individual was thinking and doing in the period before death. If a family member committed suicide, there is an increased risk that someone else in the family will also (Brent et al., 2015; Mann et al., 2005; Nock et al., 2011). In fact, among depressed patients, the strongest predictor of suicidal behavior was having a family history of suicide (Hantouche et al., 2010). Brent and colleagues (2002) noted that offspring of family members who had attempted suicide had 6 times the risk of suicide attempts compared with offspring of nonattempters. One found an increased rate of suicide in the biological relatives of adopted individuals who had committed suicide compared with a control group of adoptees who had not committed suicide (Nock et al., 2011). Also, reviewing studies of adopted children and their biological and adopted families, Brent and Mann (2005) found that adopted individuals' suicidal behavior was predicted only by suicidal behavior in their biological relatives. This suggests some biological (genetic) contribution to suicide, even if it is relatively small, although it may not be independent of genetic contribution to depression or associated disorders. As we have noted, extremely low levels of serotonin are associated with impulsivity, instability, and the tendency to overreact to situations. It is possible then that low levels of serotonin may contribute to creating a vulnerability to act impulsively. This may include killing oneself, which is sometimes an impulsive act. The studies by Brent and colleagues (2002) and Mann and colleagues (2005) suggest that transmission of vulnerabilities for a mood disorder, including the trait of impulsivity, may mediate family transmission of suicide attempts. More than 80% of people who kill themselves suffer from a psychological disorder, usually mood, substance use, or impulse control disorders (Berman, 2009; Brent & Kolko, 1990; Conwell et al., 1996; Joe, Baser, Breeden, Neighbors, & Jackson, 2006; Nock, Hwang, Sampson, & Kessler, 2009). Suicide is often associated with mood disorders, and for good reason. As many as 60% of suicides (75% of adolescent suicides) are associated with an existing mood disorder (Berman, 2009; Brent & Kolko, 1990; Oquendo et al., 2004). But many people with mood disorders do not attempt suicide, and, conversely, many people who attempt suicide do not have mood disorders. Therefore, depression and suicide, although strongly related, are still independent. Looking more closely at the relationship of mood disorder and suicide, some investigators have isolated hopelessness, a specific component of depression, as strongly predicting suicide (Beck, 1986; Goldston, Reboussin, & Daniel, 2006). But hopelessness also predicts suicide among individuals whose primary mental health problem is not depression ( Alcohol use and abuse are associated with approximately 25% to 50% of suicides and are particularly evident in suicide among college students (Lamis, Malone, Langhinrichsen-Rohling, & Ellis, 2010) and adolescents (Pompili et al., 2012; Berman, 2009; Conwell et al., 1996; Hawton, Houston, Haw, Townsend, & Harriss, 2003). In fact, Brent and colleagues (1988) found that about one third of adolescents who commit suicide were intoxicated when they died and that many more might have been under the influence of drugs. Combinations of disorders, such as substance abuse and mood disorders in adults or mood disorders and conduct disorder in children and adolescents, seem to create a stronger vulnerability than any one disorder alone A closely related trait termed sensation-seeking predicts teenage suicidal behavior as well, above and beyond its relationship with depression and substance use (Ortin, Lake, Kleinman, & Gould, 2012). Past suicide attempts are another strong risk factor and must be taken seriously (Berman, 2009). Cooper and colleagues (2005) followed almost 8,000 individuals who were treated in the emergency room for deliberate self-harm for up to 4 years. Sixty of these people later killed themselves, which equates to 30 times the rate for the general population. A disorder characterized more by impulsivity than depression is borderline personality disorder (see Chapter 12). Individuals with this disorder, known for making manipulative and impulsive suicidal gestures without necessarily wanting to destroy themselves, sometimes kill themselves by mistake in as many as 10% of the cases. The combination of borderline personality disorder and depression is particularly deadly Perhaps the most important risk factor for suicide is a severe, stressful event experienced as shameful or humiliating, such as a failure (real or imagined) in school or at work, an unexpected arrest, or rejection by a loved one (Blumenthal, 1990; Conwell et al., 2002; Joiner & Rudd, 2000). Physical and sexual abuse are also important sources of stress (

Catatonic features specifier.

This specifier can be applied to major depressive episodes whether they occur in the context of a persistent depressive order or not, and even to manic episodes, although it is rare—and rarer still in mania. This serious condition involves an absence of movement (a stuporous state) or catalepsy, in which the muscles are waxy and semirigid, so a patient's arms or legs remain in any position in which they are placed. Catatonic symptoms may also involve excessive but random or purposeless movement. Catalepsy was thought to be more commonly associated with schizophrenia, but some recent studies have suggested it may be more common in depression than in schizophrenia (Huang, Lin, Hung, & Huang, 2013).

Seasonal pattern specifier

This temporal specifier applies to recurrent major depressive disorder (and also to bipolar disorders). It accompanies episodes that occur during certain seasons (for example, winter depression). The most usual pattern is a depressive episode that begins in the late fall and ends with the beginning of spring. (In bipolar disorder, individuals may become depressed during the winter and manic during the summer.) These episodes must have occurred for at least two years with no evidence of nonseasonal major depressive episodes occurring during that period of time. This condition is called seasonal affective disorder (SAD). Unlike more severe melancholic types of depression, people with winter depressions tend toward excessive sleep (rather than decreased sleep) and increased appetite and weight gain (rather than decreased appetite and weight loss), symptoms shared with atypical depressive episodes. Although SAD seems a bit different from other major depressive episodes, family studies have not yet revealed any significant differences that would suggest winter depressions are a separate type (Lam, & Lavitan, 2000). Emerging evidence suggests that SAD may be related to daily and seasonal changes in the production of melatonin, a hormone secreted by the pineal gland. Because exposure to light suppresses melatonin production, it is produced only at night. Melatonin production also tends to increase in winter, when there is less sunlight. One theory is that increased production of melatonin might trigger depression in vulnerable people (Goodwin & Jamison, 2007; Lee et al., 1998). Wehr and colleagues (2001) have shown that melatonin secretion does increase in winter but only in patients with SAD and not healthy controls. SAD is a result of phase-delayed circadian misalignment, meaning that the patient's circadian rhythm is misaligned with the environmental day-night cycle. Bright light exposure and melatonin at wake time can, therefore, realign the patient's circadian rhythm (Lewy, Tutek, Havel, & Nikia, 2014). We come back to these treatment options below. Some clinicians reasoned that exposure to bright light might slow melatonin production in individuals with SAD (Lewy et al., 2014). In phototherapy, a current treatment, most patients are exposed to 2 hours of bright light (2,500 lux) immediately on awakening. If the light exposure is effective, the patient begins to notice a lifting of mood within 3 to 4 days and a remission of winter depression in 1 to 2 weeks. Patients are also asked to avoid bright lights in the evening (from shopping malls and the like), so as not to interfere with the effects of the morning treatments. In two of these studies (Eastman et al., 1998; Terman et al., 1998), a clever "negative ion generator" served as a placebo treatment in which patients sat in front of the box for the same amount of time as in the phototherapy and "expected" the treatment would work following instructions from the investigator but did not see the light. The results, presented in Table 7.1, showed a significantly better response for morning light compared with evening light or placebo. Evening light was better than placebo. The mechanism of action of this treatment has not been fully established, but one study indicated that morning light is superior to evening light because morning light produced phase advances of the melatonin rhythm, suggesting that changes in circadian rhythm are an important factor in treatment However, during the second winter, the CBT group, as compared to the light therapy group, showed less severe symptoms of depression, had a smaller proportion of people relapse (27.3% vs. 45.6%), and demonstrated a greater proportion of remissions (68.3% vs. 44.5%). These results suggest that CBT has greater durability than light therapy for SAD, replicating and extending an earlier study (Rohan et al., 2007).

Gender Differences in Mood Disorders

Women account for 7 out of 10 cases of major depressive disorder • Recall that women also have higher rates of anxiety disorders Women will go in for treatment more often Possible explanations for gender disparity ▪ Women socialized to have stronger perception of uncontrollability ▪ Parenting style makes girls less independent ▪ Women more sensitive to relationship disruptions (e.g., breakups, tension in friendships) ▪ Women ruminate more than men If you feel a sense of mastery over your life and the difficult events we all encounter, you might experience occasional stress, but you will not feel the helplessness central to anxiety and mood disorders. The source of these differences is cultural, in the sex roles assigned to men and women in our society. Males are strongly encouraged to be independent, masterful, and assertive; females, by contrast, are expected to be more passive, sensitive to other people, and, perhaps, to rely on others more than males do Evidence has accumulated that parenting styles encouraging stereotypic gender roles are implicated in the development of early psychological vulnerability to later depression or anxiety (Chorpita & Barlow, 1998; Barlow et al., 2013; Suárez et al., 2009), specifically, a smothering, overprotective style that prevents the child from developing initiative. Many thought this might be biologically based. Kessler (2006) notes, however, that low self-esteem emerges quickly in girls in seventh grade if the school system has a seventh- through ninth-grade middle school, but low self-esteem among girls does not emerge until ninth grade when the school has a kindergarten through eighth-grade primary school and a 4-year high school (Simmons & Blyth, 1987). These results suggest that the younger girls just entering a new school, whether it is seventh, ninth, or some other grade, find it stressful. Disruptions in such relationships, combined with an inability to cope with the disruptions, seem to be far more damaging to women than to men Women tend to ruminate more than men about their situation and blame themselves for being depressed. This response style predicted the later development of depression when under stress (Abela& Hankin, 2011). Men tend to ignore their feelings, perhaps engaging in activity to take their minds off them (Addis, 2008). This male behavior may be therapeutic because "activating" people (getting them busy doing something) is a common element of successful therapy for depression Interestingly, married women employed full time outside the home report levels of depression no greater than those of employed married men. Single, divorced, and widowed women experience significantly more depression than men in the same categories

Suicide: Facts and Statistics

• Eleventh leading cause of death in USA ▪ Underreported; actual rate may be 2 to 3 times higher • Most common among white and native Americans • Particularly prevalent in young adults ▪ Third leading cause of death among teenagers ▪ Second leading cause of death in college students ▪ 12% of college students consider suicide in a given year Suicide is officially the 11th leading cause of death in the United States (Nock, Borges, Bromet, Cha, et al., 2008), and most epidemiologists agree that the actual number of suicides may be 2 to 3 times higher than what is reported. Many of these unreported suicides occur when people deliberately drive into a bridge or off a cliff (Blumenthal, 1990), and in the past, it was not uncommon to attribute deaths by suicide to medical causes out of respect to the deceased (Marcus, 2010). Suicide is overwhelmingly a white phenomenon. Most minority groups, including African Americans and Hispanics, seldom resort to this desperate alternative. As you might expect from the incidence of depression in Native Americans, however, their suicide rate is extremely high, far outstripping the rates in other ethnic groups (Centers for Disease Control and Prevention [CDC], 2015); although there is great variability across tribes—among the Apache, the rates are nearly 4 times the national average (Mullany et al., 2009). Even more alarming is the dramatic increase in death by suicide beginning in adolescence. In 2012 in the United States, the number of deaths by suicide per 100,000 people rose from 1.73 in the 10 to 14 age group to 14.26 in the 20 to 24 age group (CDC, 2015). Firearms account for almost half of all suicides in this age group (CDC, 2015). Sadly, adolescents who are at risk for suicide have just as easy access to firearms (1 in 3 adolescents live in a home with a firearm) as those who are not at risk (Simonetti et al., 2015). There is also a dramatic increase in suicide rates among the elderly compared with rates for younger age groups. This rise has been connected to the growing incidence of medical illness in our oldest citizens and to their increasing loss of social support (Conwell, Duberstein, & Caine, 2002) and resulting depression (Fiske et al., 2009; Boen, Dalgard, & Bjertness, 2012). As we have noted, a strong relationship exists between illness or infirmity and hopelessness or depression. In addition to completed suicides, three other important indices of suicidal behavior are suicidal ideation (thinking seriously about suicide), suicidal plans (the formulation of a specific method for killing oneself), and suicidal attempts (the person survives) (Kessler et al., 2005; Nock et al., 2011). Although males commit suicide more often than females in most of the world, females attempt suicide at least 3 times as often (Berman & Jobes, 1991; Kuo et al., 2001). And the overall rate of nonlethal suicidal thoughts, plans, and (unsuccessful) attempts is 40% to 60% higher in women than in men (Nock et al., 2011). This high incidence may reflect that more women than men are depressed and that depression is strongly related to suicide attempts (Berman, 2009). It is also interesting that despite the much higher rate of completed suicides among whites, there are no significant ethnic or racial differences in rates of suicide ideation, plans, or attempts (Kessler et al., 2005).

Assessing Safety, Health and Well Being in Adults: Psychosocial Well-Being

▪ Faith & Spirituality ▪ Isolation vs Support ▪ Marriage and Intimate Relationships

Assessing Safety, Health and Well Being in Adults: Coping With Stress

▪ Outlets ▪ Social Support ▪ Predictability ▪ Sense of Control ▪ Perception of things worsening ▪ Family perception

Hypomanic episode

Hypomanic episode ▪ Shorter, less severe version of manic episodes ▪ Last at least four days ▪ Have fewer and milder symptoms ▪ Associated with less impairment than a manic episode (e.g., less risky behavior) ▪ May not be problematic in and of itself, but usually occurs in the context of a more problematic mood disorder Not Hospitalization Bipolar II DSM-5 also defines a hypomanic episode, a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning and need last only 4 days rather than a full week.

From Grief to Depression

In previous editions of the DSM, depression could not be diagnosed during periods of mourning • Now recognized that major depression may occur as part of the grieving process • Acute grief: Occurs immediately after loss • Integrated grief: Eventual coming to terms with meaning of the loss • Complicated grief: Persistent acute grief and inability to come to terms with loss The acute grief most of us would feel eventually evolves into what is called integrated grief, in which the finality of death and its consequences are acknowledged and the individual adjusts to the loss. Many of the psychological and social factors related to mood disorders in general, including a history of past depressive episodes, also predict the development of what is called the syndrome of complicated grief, although this reaction can develop without a preexisting depressed state (Bonanno, Wortman, & Nesse, 2004).

Suicide Prevention

In professional mental health ▪ Clinician does risk assessment (ideation, plans, intent, means, etc.) ▪ Clinician and patient develop safety plan (e.g., who to call, strategies for coping with suicidal thoughts) ▪ In some cases, sign no-suicide contract • Preventative programs for at-risk groups ▪ CBT can reduce suicide risk • Important: removing access to lethal methods If you think someone is at risk, talk to them and ensure they're getting needed support ▪ Talking to someone about suicide is not likely to place them at greater risk or "plant the idea" ▪ In contrast, the risk of not providing support to someone in need is huge

Tricyclic Antidepressants

Include Tofranil, Elavil • Mechanisms not well understood ▪ Block reuptake norepinephrine and other neurotransmitters • Negative side effects are common (e.g., drowsiness, weight gain) ▪ Discontinuation is common • May be lethal in excessive doses Tricyclic antidepressants seem to have their greatest effect by down-regulating norepinephrine, although other neurotransmitter systems, particularly serotonin, are also affected. This process then has a complex effect on both presynaptic and postsynaptic regulation of neurotransmitter activity, eventually restoring appropriate balance. Side effects include blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain (at least 13 pounds on average), and, sometimes, sexual dysfunction

Gender differences

Males complete more suicides than females ▪ Females attempt suicide more often than males ▪ Disparity is due to males using more lethal methods ▪ Exception: Suicide more common among women in China • May reflect cultural acceptability; suicide is seen as an honorable solution to problems Regardless of age, in every country around the world except China, males are 4 times more likely to commit suicide than females (Nock et al., 2011; World Health Organization, 2010). This startling fact seems to be related partly to gender differences in the types of suicide attempts. Males generally choose far more violent methods, such as guns and hanging; females tend to rely on less violent options, such as drug overdose (Callanan & Davis, 2012; Nock et al., 2011). More men commit suicide during old age and more women during middle age, partly because most attempts by older women are unsuccessful (Berman, 2009; Kuo, Gallo, & Tien, 2001).

Marital relations

Marital dissatisfaction is strongly related to depression ▪ This relation is particularly strong in males Depression and bipolar disorder are strongly influenced by interpersonal stress (Sheets & Craighead, 2014; Vrshek-Schallhorn et al., 2015), and especially marital dissatisfaction, as suggested earlier when it was noted that disruptions in relationships often lead to depression Approximately 21% of the women who reported a marital split during the study experienced severe depression, a rate 3 times higher than that for women who remained married. Nearly 17% of the men who reported a marital split developed severe depression, a rate 9 times higher than that for men who remained married. Depression seems to cause men to withdraw or otherwise disrupt the relationship. For women, on the other hand, problems in the relationship most often cause depression. Thus, for both men and women, depression and problems in marital relations are associated, but the causal direction is different (Fincham, Beach, Harold, & Osborne, 1997), a result also found by Spangler, Simons, Monroe, and Thase (1996). Given these factors, Beach, Jones, & Franklin (2009) suggest that therapists treat disturbed marital relationships at the same time as the mood disorder to ensure the highest level of success for the patient and the best chance of preventing future relapses. Individuals with bipolar disorder are less likely to be married at all and more likely to get divorced if they do marry, although those who stay married have a somewhat better prognosis perhaps because their spouses are helpful in regulating their treatments and keeping them on medications (Davila et al., 2009).

Psychosocial Treatments for Bipolar Disorders

Medication (usually Lithium) is still first line of defense • Psychotherapy helpful in managing the problems (e.g., interpersonal, occupational) that accompany bipolar disorder • Family therapy can be helpful Although medication, particularly lithium, seems a necessary treatment for bipolar disorder, most clinicians emphasize the need for psychological interventions to manage interpersonal and practical problems (for example, marital and job difficulties that result from the disorder) For example, Clarkin, Carpenter, Hull, Wilner, and Glick (1998) evaluated the advantages of adding a psychological treatment to medication in inpatients and found it improved adherence to medication for all patients and resulted in better overall outcomes for the most severe patients compared with medication alone. David Miklowitz and his colleagues found that family tension is associated with relapse in bipolar disorder. Preliminary studies indicate that treatments directed at helping families understand symptoms and develop new coping skills and communication styles do change communication styles (Simoneau, Miklowitz, Richards, Saleem, & George, 1999) and prevent relapse (Miklowitz, 2014). Miklowitz, George, Richards, Simoneau, and Suddath (2003) demonstrated that their family-focused treatment combined with medication results in significantly less relapse 1 year following initiation of treatment than occurs in patients receiving crisis management and medication over the same period (see Figure 7.10).

Melancholic features specifier.

Melancholic features specifier. This specifier applies only if the full criteria for a major depressive episode have been met, whether in the context of a persistent depressive disorder or not. Melancholic specifiers include some of the more severe somatic (physical) symptoms, such as early-morning awakenings, weight loss, loss of libido (sex drive), excessive or inappropriate guilt, and anhedonia (diminished interest or pleasure in activities). The concept of "melancholic" does seem to signify a severe type of depressive episode.

Cognitive Theory

Negative coping styles ▪ Depressed persons engage in cognitive errors ▪ Tendency to interpret life events negatively • Types of cognitive errors ▪ Arbitrary inference - overemphasize the negative aspects of a mixed situation ▪ Overgeneralization - negatives apply to all situations Cognitive errors and the depressive cognitive triad ▪ Think negatively about oneself ▪ Think negatively about the world ▪ Think negatively about the future In a self-blame schema, individuals feel personally responsible for every bad thing that happens. With a negative self-evaluation schema, they believe they can never do anything correctly. In Beck's view, these cognitive errors and schemas are automatic, that is, not necessarily conscious. Indeed, an individual might not even be aware of thinking negatively and illogically. Depressive cognitions seem to emerge from distorted and probably automatic methods of processing information. People prone to depression are more likely to recall negative events when they are depressed than when they are not depressed or than are nondepressed individuals (Gotlib et al., 2014). Individuals with bipolar disorder also exhibit negative cognitive styles, but with a twist. Cognitive styles in these individuals are characterized by ambitious striving for goals, perfectionism, and self-criticism in addition to the more usual depressive cognitive styles Results indicated students at high risk because of dysfunctional attitudes reported higher rates of depression in the past compared with the low-risk group. But the really important results come from the prospective portion of the study. Negative cognitive styles do indicate a vulnerability to later depression. Even if participants had never suffered from depression before in their lives, high-risk participants (who scored high on the measures of cognitive vulnerability) were 6 to 12 times more likely than low-risk participants to experience a major depressive episode.

Combined Treatments for Depression

Nevertheless, the consensus is that combined treatment does provide some advantage. Notice how this conclusion differs from the conclusion in Chapter 5 on anxiety disorders, where no advantage of combining treatments was apparent. But combining two treatments is also expensive, so many experts think that it makes more sense to use a sequential strategy, in which you start with one treatment (maybe the one the patient prefers or the one that's most convenient) and then switch to the other only if the first choice is not entirely satisfactory (see, for example, Lynch et al., 2011; Payne et al., in press; Schatzberg et al., 2005).

Peripartum onset specifier.

Peri means "surrounding," in this case the period of time just before and just after the birth. This specifier can apply to both major depressive and manic episodes. Between 13% and 19% of all women giving birth (one in eight) meet criteria for a diagnosis of depression, referred to as peripartum depression. Of the mothers, 10% showed a marked increase in depressive symptoms on a rating scale, but so did 4% of the fathers. If you extend the period from the first trimester to one year after birth, the rate of depression is approximately 10% for fathers and as high as 40% for mothers. And depression in fathers was associated with adverse emotional and behavioral outcomes in children 3.5 years later (Paulson & Bazemore, 2010). More minor reactions in adjustment to childbirth—called the "baby blues"—typically last a few days and occur in 40% to 80% of women between 1 and 5 days after delivery. During this period, new mothers may be tearful and have some temporary mood swings, but these are normal responses to the stresses of childbirth and disappear quickly; the peripartum onset specifier does not apply to them

Psychotic features specifiers

Psychotic features specifiers. Some individuals in the midst of a major depressive (or manic) episode may experience psychotic symptoms, specifically hallucinations (seeing or hearing things that aren't there) and delusions (strongly held but inaccurate beliefs) (Rothschild, 2013).

Onset and Duration of Depressive Disorders

Rare in childhood • Risk increases in adolescence and young adulthood, decreases in middle adulthood, increases again in old age (U-shaped pattern) • Depressive episodes are variable in length ▪ Usually last several months untreated, but may last several years Generally the risk for developing major depression is fairly low until the early teens, when it begins to rise in a steady (linear) fashion (Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013). A longitudinal study with 2,320 individuals from the Baltimore Longitudinal Study of Aging spanning from age 19 to 95 showed that symptoms of depression followed a U-shaped pattern, such that symptoms of depression were highest in young adults, decreased across middle adulthood, and then increased again in older age, with older people also experiencing an increase in distress associated with these symptoms (Sutin et al., 2013). As we noted previously, the length of depressive episodes is variable, with some lasting as little as 2 weeks; in more severe cases, an episode might last for several years, with the typical duration of the first episode being 2 to 9 months if untreated (Angst, 2009; Boland & Keller, 2009; Rohde et al., 2013). Although 9 months is a long time to suffer with a severe depressive episode, evidence indicates that, even in the most severe cases, the probability of remission of the episode within 1 year approaches 90% Persistent depressive disorder may last 20 to 30 years or more, although studies have reported a median duration of approximately 5 years in adults (Klein et al., 2006) and 4 years in children (Kovacs et al., 1994). Klein and colleagues (2006), in the study mentioned earlier, conducted a 10-year follow-up of 97 adults with DSM-IV dysthymia (now known as persistent depressive disorder, which is characterized by fewer or more mild symptoms of depression) and found that 74% had recovered at some point but 71% of those had relapsed. Even worse, patients with persistent depressive disorder with less severe depressive symptoms (dysthymia) were more likely to attempt suicide than a comparison group with (nonpersistent) episodes of major depressive disorder during a 5-year period. As noted above, it is relatively common for major depressive episodes and dysthymia (now persistent depressive disorder) to co-occur (double depression)

DSM-5 Criteria: Disruptive Mood Dysregulation Disorder

Recurring temper outbursts • Outbursts inconsistent with development • 3 or more times a week • Persistent irritability • Between 6 to 18 years old • Onset 10 years old Severe recurrent temper outburst manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. The temper outbursts are inconsistent with developmental level. The temper outbursts occur, on average, three or more times per week. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. The diagnosis should not be made for the first time before age 6 years or after age 18 years. By history or observation, the age at onset of Criteria A-E is before 10 years. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Preventing Relapse

Research on relapse prevention is relatively less common • Psychosocial and pharmacological treatments are both used • Psychosocial interventions generally more effective at preventing relapse Moreover, it is possible that medication, when it works, does so more quickly than psychological treatments for the most part, which in turn have the advantage of increasing the patient's long-range social functioning (particularly in the case of IPT) and protecting against relapse or recurrence (particularly CBT). Combining treatments, therefore, might take advantage of the drugs' rapid action and the psychosocial protection against recurrence or relapse, thereby allowing eventual discontinuation of the medications. Therefore, one important question has to do with maintenance treatment to prevent relapse or recurrence over the long term. In a number of studies, cognitive therapy reduced rates of subsequent relapse in depressed patients by more than 50% over groups treated with antidepressant medication The study showed that, overall, both CBT and the SSRI prevented relapse equally well and more so than the placebo. Interestingly, relapse rates after having received CBT and fluoxetine did not differ.

Neurotransmitter systems

Serotonin and its relation to other neurotransmitters • Serotonin regulates norepinephrine and dopamine ▪ Mood disorders are related to low levels of serotonin ▪ Permissive hypothesis: Low serotonin "permits" other neurotransmitters to vary more widely, increasing vulnerability to depression Research implicates low levels of serotonin in the causes of mood disorders, but only in relation to other neurotransmitters, including norepinephrine and dopamine (see, for example, Thase, 2005, 2009). Remember that the apparent primary function of serotonin is to regulate our emotional reactions. According to the "permissive" hypothesis, when serotonin levels are low, other neurotransmitters are "permitted" to range more widely, become dysregulated, and contribute to mood irregularities, including depression. Current thinking is that the balance of the various neurotransmitters and their interaction with systems of self-regulation are more important than the absolute level of any one neurotransmitter Chronic stress also reduces dopamine levels and produces depressive-like behavior (Thase, 2009). But, as with other research in this area, it is quite difficult to pin down any relationships with certainty.

Premenstrual Dysphoric Disorder

Significant depressive symptoms occurring prior to menses during the majority of cycles, leading to distress or impairment ▪ Controversial diagnosis • Advantage: Legitimizes the difficulties some women face when symptoms are very severe • Disadvantage: Pathologizes an experience many consider to be normal Basically clinicians identified a small group of women, from 2% to 5%, who suffered from severe and sometimes incapacitating emotional reactions during the premenstrual period (Epperson et al., 2012). But strong objections to making this condition an official diagnosis were based on concerns that women who were experiencing a very normal monthly physiological cycle, as part of being female, would now be classified as having a disorder, which would be very stigmatizing. As noted above, the history of this controversy is described in Chapter 3. It has now been clearly established that this small group of women differs in a number of ways from the 20% to 40% of women who experience uncomfortable premenstrual symptoms (PMS) that, nevertheless, are not associated with impairment of functioning.

Sleep and Circadian Rhythms

Sleep disturbance ▪ Hallmark of most mood disorders ▪ Depressed patients have quicker and more intense REM sleep ▪ Sleep deprivation may temporarily improve depressive symptoms in bipolar patients In addition to entering REM sleep more quickly, depressed patients experience REM activity that is more intense, and the stages of deepest sleep, called slow wave sleep, don't occur until later, if at all (Jindal et al., 2002; Kupfer, 1995; Thase, 2009). It seems that some sleep characteristics occur only while we are depressed and not at other times Sleep pattern disturbances in depressed children are less pronounced than in adults, perhaps because children are very deep sleepers, illustrating once again the importance of developmental stage to psychopathology (Brent & Birmaher, 2009; Garber et al., 2009). But sleep disturbances are even more severe among depressed older adults. In fact, insomnia, frequently experienced by older adults, is a risk factor for both the onset and persistence of depression (Fiske et al., 2009; Perlis et al., 2006; Talbot et al., 2012). In an interesting study, researchers found that treating insomnia directly in those patients who have both insomnia and depression may enhance the effects of treatment for depression Treating the insomnia of bipolar I patients between episodes with CBT has been shown to reduce the risk of relapse and improve sleep, mood, and functioning (Harvey et al., 2015). Thus, it seems that the relationship between sleep and mood may cut across different diagnoses and that treating sleep disruptions directly might positively affect mood not only in insomnia but also in mood disorders Finally, abnormal sleep profiles and, specifically, disturbances in REM sleep and poor sleep quality predict a somewhat poorer response to psychological treatment (Buysse et al., 1999; Thase, 2009; Thase, Simons, & Reynolds, 1996), further supporting the potential usefulness of treating disrupted sleep directly.

Social Support

Social support ▪ Extent of social support is related to depression ▪ Lack of social support predicts late onset depression ▪ Substantial social support predicts recovery from depression To take one example, the risk of depression for people who live alone is almost 80% higher than for people who live with others (Pulkki-Råback et al., 2012) In an early landmark study, Brown and Harris (1978) first suggested the important role of social support in the onset of depression. In a study of a large number of women who had experienced a serious life stress, they discovered that only 10% of the women who had a friend in whom they could confide became depressed, compared with 37% of the women who did not have a close supportive relationship. A socially supportive network of friends and family helped speed recovery from depressive episodes but not from manic episodes

Suicide Contagion

Some research indicates that a person is more likely to commit suicide after hearing about someone else committing suicide • Media accounts may worsen the problem by ▪ Sensationalizing/romanticizing suicide ▪ Describing lethal methods of committing suicide Some people react by attempting suicide themselves, often by the same method they have just heard about. Gould (1990) reported an increase in suicides during a 9-day period after widespread publicity about a suicide, and a recent review found a positive relationship between suicidal behavior and exposure to media coverage related to suicide (Sisask & Varnik, 2012). Clusters of suicides (several people copying one person) seem to predominate among teenagers, with as many as 5% of all teenage suicides reflecting an imitation To prevent these tragedies, mental health professionals must intervene immediately in schools and other locations with people who might be depressed or otherwise vulnerable to the contagion of suicide (Boyce, 2011). But it isn't clear that suicide is "contagious" in the infectious disease sense. Rather, the stress of a friend's suicide or some other major stress may affect several individuals who are vulnerable because of existing psychological disorders

Age-Based Influences on Older Adults

Some studies estimate that 14% to 42% of nursing home residents may experience major depressive episodes (Djernes, 2006; Fiske et al., 2009). In one large study, depressed elderly patients between 56 and 85 years of age were followed for 6 years; approximately 80% did not remit but continued to be depressed (or cycled in and out of depression) even if their depressive symptoms were not severe enough to meet diagnostic criteria for a disorder (Beekman et al., 2002). Late-onset depressions are associated with marked sleep difficulties, illness anxiety disorder (anxiety focused on possibly being sick or injured in some way), and agitation (Baldwin, 2009). It can be difficult to diagnose depression in older adults, because elderly people who become physically ill or begin to show signs of dementia might become depressed about it, but the signs of depression or mood disorder would be attributed to the illness or dementia and thus missed Anxiety disorders accompany depression in from one third to one half of elderly patients, particularly generalized anxiety disorder and panic disorder (Fiske et al., 2009; Lenze et al., 2000), and when they do, patients are more severely depressed. For example, Galatzer-Levy and Bonanno (2014) studied more than 2,000 older adults from 6 years prior to their first heart attack to 4 years after their first heart attack. People were more likely to die if they became depressed after their first heart attack, as compared with people who did not become depressed. However, optimism measured before the heart attack distinguished all people who became depressed from those who did not become depressed after the first heart attack, suggesting that optimism prospectively predicted depression and thereby also mortality following the first heart attack. The earlier gender imbalance in depression lessens considerably after the age of 65. In early childhood, boys are more likely to be depressed than girls, but an overwhelming surge of depression in adolescent girls produces an imbalance in the sex ratio that is maintained until old age, when just as many women are depressed but increasing numbers of men are also affected

Diagnostic Specifiers for Depressive Disorders

Specifier: Additional diagnostic label used by clinicians to convey extra information about symptoms • Specifiers are not mandatory; only assigned if appropriate Psychotic features specifier ▪ Major depressive episodes which also include some psychotic features • Hallucinations: Sensory experience in the absence of sensory input • Delusions: Strongly held inaccurate beliefs • Anxious distress specifier ▪ Depression is accompanied by several significant symptoms of anxiety ▪ Predicts poorer outcome Mixed features specifier ▪ Depressive episodes which also include several manic symptoms • Melancholic features specifier ▪ Major depressive episode accompanied by additional severe symptoms such as early morning awakenings, lack of reactivity to positive stimuli Catatonic features specifier: ▪ Extremely rare muscular symptoms such as remaining in a still stupor, "waxy" limbs that remain in place when manipulated, repetitive or purposeless movement • Atypical features specifier: ▪ Presence of several symptoms less common in depression, including oversleeping and overeating Peripartum onset specifier: ▪ Depression occurring around the time of giving birth • Seasonal pattern specifier: Depression occurring primarily in certain seasons (usually winter) ▪ Sometimes called seasonal affective disorder. ▪ Result of phase-delayed circadian misalignment, meaning that the patient's circadian rhythm is misaligned with the environmental day-night cycle ▪ May be treated effectively with light therapy

Onset and Duration

The average age of onset for bipolar I disorder is from 15 to 18 and for bipolar II disorder from 19 and 22, although cases of both can begin in childhood (Angst, 2009; Judd et al., 2003; Merikangas & Pato, 2009). This is somewhat younger than the average age of onset for major depressive disorder, and bipolar disorders begin more acutely; that is, they develop more suddenly (Angst & Sellaro, 2000; Johnson et al., 2009). About one third of the cases of bipolar disorder begin in adolescence, and the onset is often preceded by minor oscillations in mood or mild cyclothymic mood swings (Goodwin & Jamison, 2007; Merikangas et al., 2007). It is relatively rare for someone to develop bipolar disorder after the age of 40. Once it does appear, the course is chronic; that is, mania and depression alternate indefinitely. Therapy usually involves managing the disorder with ongoing drug regimens that prevent recurrence of episodes. Bipolar disorder is associated with a high risk of suicide attempts and suicide death, the latter being associated with male sex and having a first-degree relative who committed suicide (Schaffer et al., 2015). The risk of suicide is not limited to Western countries but occurs in countries around the world (Merikangas et al., 2011). In typical cases, cyclothymia is chronic and lifelong. In about one third to one half of patients, cyclothymic mood swings develop into full-blown bipolar disorder (Kochman et al., 2005; Parker et al., 2012). In one sample of cyclothymic patients, 60% were female, and the age of onset was often during the teenage years or before, with some data suggesting the most common age of onset to be 12 to 14 years (Goodwin & Jamison, 2007).

The Endocrine System

The endocrine system ▪ Elevated cortisol ▪ Stress hormones decrease neurogenesis in the hippocampus > less able to make new neurons This hypothesis focuses on overactivity in the hypothalamic-pituitary-adrenocortical (HPA) axis (discussed later), which produces stress hormones. Again, notice the similarity with the description of the neurobiology of anxiety in Chapter 5 (see, for example, Barlow et al., 2014; Britton & Rauch, 2009; Charney & Drevets, 2002). Investigators became interested in the endocrine system when they noticed that patients with diseases affecting this system sometimes became depressed. Investigators have also discovered that neurotransmitter activity in the hypothalamus regulates the release of hormones that affect the HPA axis. These neurohormones are an increasingly important focus of study in psychopathology (see, for example, Garlow & Nemeroff, 2003; Hammen & Keenan-Miller, 2013; Nemeroff, 2004; Thase, 2009). The hippocampus, among other things, is responsible for keeping stress hormones in check and serves important functions in facilitating cognitive processes such as short-term memory. But the new finding, at least in animals, is that long-term overproduction of stress hormones makes the organism unable to develop new neurons (neurogenesis). Thus, some theorists suspect that the connection between high stress hormones and depression is the suppression of neurogenesis in the hippocampus (Glasper, Schoenfeld, & Gould, 2012; Heim, Plotsky, & Nemeroff, 2004; Snyder, Soumier, Brewer, Pickel, & Cameron, 2011; Thase, 2009). Evidence reveals that healthy girls at risk for developing depression because their mothers suffer from recurrent depression have reduced hippocampal volume compared with girls with nondepressed mothers (Chen, Hamilton, & Gotlib, 2010). This finding suggests that low hippocampal volume may precede and perhaps contribute to the onset of depression. Scientists have already observed that successful treatments for depression, including electroconvulsive therapy, seem to produce neurogenesis in the hippocampus, thereby reversing this process

Prevalence in Children, Adolescents, and Older Adults

The general conclusion is that depressive disorders occur less often in prepubertal children than in adults but rise dramatically in adolescence Adolescents experience major depressive disorder about as often as adults (Kessler et al., 2012; Rohde et al., 2013; Rudolph, 2009). In children, the sex ratio for depressive disorders is approximately 50:50, but this changes dramatically in adolescence. Major depressive disorder in adolescents is largely a female disorder The overall prevalence of major depressive disorder for individuals over 65 is about half that of the general population (Blazer & Hybels, 2009; Byers, Yaffe, Covinsky, Friedman, & Bruce, 2010; Fiske, Wetherell, & Gatz, 2009; Hasin et al., 2005; Kessler et al., 2003), perhaps because stressful life events that trigger major depressive episodes decrease with age. But milder symptoms that do not meet criteria for major depressive disorder seem to be more common among the elderly Bipolar disorder seems to occur at about the same rate (1%) in childhood and adolescence as in adults (Brent & Birmaher, 2009; Kessler et al., 2012; Merikangas & Pato, 2009). The rates of diagnosis of bipolar disorder in clinics has increased substantially, however, due to greater interest and a controversial tendency described above to broaden the diagnostic criteria in children to include what will now be subsumed under disruptive mood dysregulation disorder.

Causes

The great sociologist Emile Durkheim (1951) defined a number of suicide types, based on the social or cultural conditions in which they occurred. One type is "formalized" suicides that were approved of, such as the ancient custom of hara-kiri in Japan, in which an individual who brought dishonor to himself or his family was expected to impale himself on a sword. Durkheim referred to this as altruistic suicide. Durkheim also recognized the loss of social supports as an important provocation for suicide; he called this egoistic suicide. (Older adults who kill themselves after losing touch with their friends or family fit into this category.) Magne-Ingvar, Ojehagen, and Traskman-Bendz (1992) found that only 13% of 75 individuals who had seriously attempted suicide had an adequate social network of friends and relationships. Similarly, a recent study found that suicide attempters perceived themselves to have lower social support than did non-attempters (Riihimaki, Vuorilehto, Melartin, Haukka, & Isometsa, 2013). Anomic suicides are the result of marked disruptions, such as the sudden loss of a high-prestige job. (Anomie is feeling lost and confused.) Finally, fatalistic suicides result from a loss of control over one's own destiny.

Learned Helplessness

The learned helplessness theory of depression ▪ Lack of perceived control over life events leads to decreased attempts to improve own situation ▪ First demonstrated in research by Martin Seligman ▪ Negative cognitive styles are a risk factor for depression Depression may follow marked hopelessness about coping with the difficult life events (Barlow, 1988, 2002). The depressive attributional style is internal, in that the individual attributes negative events to personal failings ("it is all my fault"); stable, in that, even after a particular negative event passes, the attribution that "additional bad things will always be my fault" remains; and global, in that the attributions extend across a variety of issues. Results from a classic 5-year longitudinal study of children shed some light on this issue. Nolen-Hoeksema, Girgus, and Seligman (1992) reported that negative attributional style did not predict later symptoms of depression in young children; rather, stressful life events seemed to be the major precipitant of symptoms. As children under stress grew older, however, they tended to develop more negative cognitive styles, which did tend to predict symptoms of depression in reaction to additional negative events. Nolen-Hoeksema and colleagues speculate that meaningful negative events early in childhood may lead to negative attributional styles, making these children more vulnerable to future depressive episodes when stressful events occur. Indeed, most studies support the finding that negative cognitive styles precede and are a risk factor for depression Evidence suggests that negative attributional styles are not specific to depression but also characterize people with anxiety (Barlow, 2002; Hankin & Abramson, 2001; Barlow et al., 2013). This may indicate that a psychological (cognitive) vulnerability is no more specific for mood disorders than a genetic vulnerability. Both types of vulnerabilities may underlie numerous disorders. Attributions are important only to the extent that they contribute to a sense of hopelessness. This fits well with recent thinking on crucial differences between anxiety and depression. Both anxious and depressed individuals feel helpless and believe they lack control, but only in depression do they give up and become hopeless about ever regaining control

Atypical features specifier.

This specifier applies to both depressive episodes, whether in the context of persistent depressive disorder or not. While most people with depression sleep less and lose their appetite, individuals with this specifier consistently oversleep and overeat during their depression and therefore gain weight, leading to a higher incidence of diabetes (Glaus et al., 2012; Kessler & Wang, 2009). Although they also have considerable anxiety, they can react with interest or pleasure to some things, unlike most depressed individuals. In addition, depression with atypical features, compared with more typical depression, is associated with a greater percentage of women and an earlier age of onset. The atypical group also has more symptoms, more severe symptoms, more suicide attempts, and higher rates of comorbid disorders including alcohol abuse

The Structure of Mood Disorders

Unipolar mood disorder: Only one extreme of mood is experienced ▪ E.g., only depression or only mania ▪ Depression alone is much more common than mania alone • Bipolar mood disorder: Both depressed and elevated moods are experienced ▪ E.g., some depressive episodes and some manic or hypomanic episodes If they do, does the patient recover fully for at least two months between episodes (termed "full remission") or only partially recover retaining some depressive symptoms ("partial remission")? Do the depressive episodes alternate with manic or hypomanic episodes or not? All these patterns for mood disorders are important to note, since they contribute to decisions on which diagnosis is appropriate.

Transcranial Magnetic Stimulation

Uses magnets to generate a precise localized electromagnetic pulse • Few side effects; occasional headaches • Less effective than ECT for medication- resistant depression • May be combined with medication This procedure is called transcranial magnetic stimulation (TMS), and it works by placing a magnetic coil over the individual's head to generate a precisely localized electromagnetic pulse. Anesthesia is not required, and side effects are usually limited to headaches. Initial reports, as with most new procedures, showed promise in treating depression (George, Taylor, & Short, 2013), and recent observations and reviews have confirmed that TMS can be effective (Mantovani et al., 2012; Schutter, 2009; De Raedt et al., 2015). But results from several important clinical trials with severe or treatment-resistant psychotic depression reported ECT to be clearly more effective than TMS

Prevalence of Mood Disorders

Worldwide lifetime prevalence of MDD: 16% • 6% have experienced major depression in last year • Sex differences ▪ Females are twice as likely to have major depression ▪ Bipolar disorders approximately equally affect males and females ▪ Women more likely to experience rapid cycling ▪ Women more likely to be in depressive period Occurs less often in prepubertal children • Rapid rise in adolescents • Adults over 65 have about 50% less prevalence than general population • Bipolar same in childhood, adolescence, and adults • Prevalence of depression seems to be similar across subcultures Studies indicate that women are twice as likely to have mood disorders as men (Kessler, 2006; Kessler & Wang, 2009), but the imbalance in prevalence between males and females is accounted for solely by major depressive disorder and persistent depressive disorder (dysthymia), because bipolar disorders are distributed approximately equally across gender (Merikangas & Pato, 2009). Although equally prevalent, there are some sex-based differences in bipolar disorder. As noted above, women are more likely than men to experience rapid cycling, but also to be anxious, and to be in a depressive phase rather than a manic phase (Altshuler et al., 2010). It is interesting that the prevalence of major depressive disorder and persistent depressive disorder (dysthymia) is significantly lower among blacks than among whites (Hasin et al., 2005), although, again, no differences appear in bipolar disorders. Native Americans, on the other hand, present with a significantly higher prevalence of depression (Hasin et al., 2005), although difficulties in translating the concept of depression to Native American cultures suggest this finding needs more study

"Mixed features"

• "Mixed features" = term for a mood episode with some elements reflecting the opposite valence of mood ▪ Example: Depressive episode with some manic features ▪ Example: Manic episode with some depressed/anxious features

Cognitive-behavioral therapy

▪ Addresses cognitive errors in thinking ▪ Also includes behavioral components including behavioral activation (scheduling valued activities) Beck's cognitive therapy grew directly out of his observations of the role of deep-seated negative thinking in generating depression (Beck, 1967, 1976; Young et al., 2014). Clients are taught to examine carefully their thought processes while they are depressed and to recognize "depressive" errors in thinking. This task is not always easy, because many thoughts are automatic and beyond clients' awareness. Clients are taught that errors in thinking can directly cause depression. Treatment involves correcting cognitive errors and substituting less depressing and (perhaps) more realistic thoughts and appraisals. inally, mindfulness-based therapy has been found to be effective for treating depression (Hofmann, Sawyer, Witt, & Oh, 2010; Khoury et al., 2013) and preventing future depressive relapse and recurrence (Kuyken et al., 2015). These techniques have also been combined with cognitive therapy in mindfulness-based cognitive therapy (MBCT) (Barnhofer et al., in press; Michalak, Schultze, Heidenreich, & Schramm, 2015; Williams, Teasdale, Segal, & Kabat-Zinn, 2007; Segal, Williams, & Teasdale, 2002). MBCT has been evaluated and found effective for the most part in the context of preventing relapse or recurrence in patients who are in remission from their depressive episode. This approach seems particularly effective for individuals with more severe disorders, as indicated by a history of three or more prior depressive episodes (Segal et al., 2002; Segal et al., 2010). Babyak and colleagues (2000) demonstrated that programmed aerobic exercise 3 times a week was as effective as treatment with antidepressive medication (Zoloft) or the combination of exercise and Zoloft after 4 months. More important, exercise was better at preventing relapse in the 6 months following treatment compared with the drug or combination treatment, particularly if the patients continued exercising. It was noted above that there is some new evidence that exercise increases neurogenesis in the hippocampus, which is known to be associated with resilience to depression. This general approach of focusing on fitness activities is also consistent with findings about the most powerful methods to change dysregulated emotions

Assessing Safety, Health and Well Being in Adults: Suicide Assessment

▪ Male Female Paradox ▪ In the US, the male-to-female suicide death ratio varies between 3:1 to 10:1. ▪ Typically males die from suicide three to four times more often as females, and, in some cases, five or more times as often. Female attempt suicide 5x more Women: pills, cutting Co2 Men: guns, hanging, driving Females report attempting suicide at a higher rate than males in the United States . to receive a psychiatric affective diagnosis . ▪ While 72-89% of females who committed suicide had contact with a mental health professional at some point in their life, only 41-58% of males who committed suicide had made use of this resource. Suicide Predictors: ▪ Men above 60, Adults 15-30 (high risk). ▪ Marital Status ▪ Mental Health Issues ▪ Losses Suicide Predictors: ▪ Substance Use ▪ Lethal Means ▪ Childhood Trauma ▪ Family Community Completed Suicide (9:1) ▪ Interviewing ▪ Normalization ▪ Details of plan(s) ▪ Behavioral Incidents ▪ Denial of Specific ▪ Ensuring safety

Life Span Developmental Influences on Mood Disorders

3-month-olds can show depressive symptoms • Young children typically don't show classic mania or bipolar symptoms • Mood disorder may be misdiagnosed as ADHD • Children are being diagnosed with bipolar disorders at increasingly high rates • Depression in elderly between 14% and 42% ▪ Co-occurrence with anxiety disorders ▪ Less gender imbalance after 65 years of age There is some evidence that 3-month-old babies can become depressed! Infants of depressed mothers display marked depressive behaviors (sad faces, slow movement, lack of responsiveness) even when interacting with a nondepressed adult (Garber et al., 2009; Guedeney, 2007). Whether this behavior or temperament is caused by a genetic tendency inherited from the mother, the result of early interaction patterns with a depressed mother or primary caregiver, or a combination is not yet clear. Most investigators agree that mood disorders are fundamentally similar in children and in adults (Brent & Birmaher, 2009; Garber et al., 2009; Weiss & Garber, 2003). Therefore, no "childhood" mood disorders in DSM-5 are specific to a developmental stage, with the exception of disruptive mood dysregulation disorder which can be diagnosed only up to 12 years of age. One developmental difference between children and adolescents compared with adults concerns patterns of comorbidity. For example, childhood depression (and mania) is often associated with and sometimes misdiagnosed as ADHD or, more often, conduct disorder in which aggression and even destructive behavior are common (Fields & Fristad, 2009; Garber et al., 2009). Conduct disorder and depression often co-occur in bipolar disorder. But, once again, many of these children might now meet criteria for disruptive mood dysregulation disorder, which would better account for this comorbidity. Fergusson and Woodward (2002), in a large prospective study, identified 13% of a group of 1,265 adolescents who developed major depressive disorder between 14 and 16 years of age. Later, between ages 16 and 21, this group was significantly at risk for occurrence of major depression, anxiety disorders, nicotine dependence, suicide attempts, and drug and alcohol abuse, as well as educational underachievement and early parenting, compared with adolescents who were not depressed. Weissman and colleagues (1999) identified a group of 83 children with an onset of major depressive disorder before puberty and followed them for 10 to 15 years. Generally, there was also a poor adult outcome in this group, with high rates of suicide attempts and social impairment, compared with children without major depressive disorder. Interestingly, these prepubertal children were more likely to develop substance abuse or other disorders as adults than to continue with their depression, unlike adolescents with major depressive disorder.

DSM-5 Criteria: Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 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 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (e.g., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another general medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence of a manic episode and, therefore, a bipolar I diagnosis.

DSM-5 Criteria: Bipolar II Disorder

A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode. Criteria for a hypomanic episode are identical to those for a manic episode (see DSM-5 Table 7.2), with the following distinctions: 1) Minimum duration is 4 days; 2) Although the episode represents a definite change in functioning, it is not severe enough to cause marked social or occupational impairment or hospitalization; 3) There are no psychotic features. B. There has never been a manic episode. C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify current or most recent episode: Hypomanic: If currently (or most recently) in a hypomanic episode Depressed: If currently (or most recently) in a major depressive episode Specify if: With anxious distress; With mixed features; With rapid cycling ; With mood-congruent psychotic features; With mood-incongruent psychotic features; With catatonia; With peripartum onset; With seasonal pattern Specify course if full criteria for a mood episode are not currently met: In full remission, in partial remission Specify severity if full criteria for a mood episode are currently met: Mild, moderate, severe

DSM-5 Criteria: Persisent Depressive Disorder (Dysthymia)

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year. B. Presence, while depressed, of two (or more) of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time. D. Criteria for major depressive disorder may be continuously present for 2 years. E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Current severity: Mild, moderate, severe; With anxious distress; With mixed features; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With peripartum onset; Early onset: If onset is before age 21 years; Late onset: if onset is at age 21 years or older; specify (for most recent 2 years of dysthymic disorder): With pure dysthymic syndrome: if full criteria for a major depressive episode have not been met in at least the preceding 2 years. With persistent major depressive episode: if full criteria for a major depressive episode have been met throughout the preceding 2-year period. With intermittent major depressive episodes, with current episode: if full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode. With intermittent major depressive episodes, without current episode: if full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years. In full remission, in partial remission

DSM-5 Criteria: Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations. 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). Note: in children and adolescents can be irritable mood. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gains 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). Children: Personality differences, friends, siblings, teachers

DSM-5 Criteria: Cyclothymic Disorder

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms in criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With anxious distress

Assessing Safety, Health and Well Being in Adults: Harm to Others

ACTION (Borum and Ready, 2001) ACTION (Borum and Ready, 2001) ▪ Attitudes ▪ Capacity ▪ Thresholds crossed ▪ Intent ▪ Others reactions ▪ Noncompliance with risk reduction Other Factors ▪ History of Violence ▪ Mental instability ▪ Substance Use ▪ Legal Issues Duty to Warn (Tarasoff)

Across Cultures

Across Cultures ▪ Similar prevalence among U.S. subcultures, but experience of symptoms may vary • E.g., some cultures more likely to express depression as somatic concern ▪ Higher prevalence among Native Americans: Four times the rate of the general population We noted the strong tendency of anxiety to take somatic (physical) forms in some cultures; instead of talking about fear, panic, or general anxiety, many people describe stomachaches, chest pains or heart distress, and headaches. Much the same tendency exists across cultures for mood disorders (Kim & Lopez, 2014), which is not surprising given the close relationship of anxiety and depression Some cultures have their own idioms for depression; for instance, the Hopi, a Native American tribe, say they are "heartbroken" (Manson & Good, 1993), whereas aboriginal men in central Australia who are clearly depressed attribute it to weakness or injury of the spirit (Brown, Scales, et al., 2012). The way people think of depression may be influenced by the cultural view of the individual and the role of the individual in society (Kleinman, 2004; Ryder et al., 2008). For example, in societies that focus on the individual instead of the group, it is common to hear statements such as, "I feel blue" or "I am depressed." In cultures where the individual is tightly integrated into the larger group, however, someone might say, "Our life has lost its meaning," referring to the group in which the individual resides (Manson & Good, 1993). In specific locations, prevalence of depression can differ dramatically. A structured interview was used by Kinzie, Leung, Boehnlein, and Matsunaga (1992) to determine the percentage of adult members of a Native American village who met criteria for mood disorders. The lifetime prevalence for any mood disorder was 19.4% in men, 36.7% in women, and 28% overall, approximately 4 times higher than in the general population. Examined by disorder, almost all the increase is accounted for by greatly elevated rates of major depression. Findings in the same village for substance abuse are similar to the results for major depressive disorder

Diagnostic Specifiers for Bipolar Disorders

All of the specifiers for depressive disorders may also apply to bipolar disorders • Additional specifer unique to bipolar disorders: Rapid cycling specifier ▪ Moving quickly in and out of mania and depression ▪ Individual experiences at least four manic or depressive episodes within a year ▪ Occurs in between 20 to 50% of cases ▪ Associated with greater severity Fortunately, rapid cycling does not seem to be permanent, because only 3% to 5% of patients continue with rapid cycling across a 5-year period (Schneck et al., 2008), with 80% returning to a non-rapid-cycling pattern within 2 years (Coryell et al., 2003). There are also cases of ultra-rapid cycle lengths that only last for days to weeks and ultra-ultra-rapid cycling in cases where cycle lengths are less than 24 hours

mixed reuptake inhibitors

Another class of antidepressants (sometimes termed mixed reuptake inhibitors) seem to have somewhat different mechanisms of neurobiological action. The best known, venlafaxine (Effexor) is related to tricyclic antidepressants, but acts in a slightly different manner, blocking reuptake of norepinephrine as well as serotonin. Some side effects associated with the SSRIs are reduced with venlafaxine, as is the risk of damage to the cardiovascular system. Other typical side effects remain, including nausea and sexual dysfunction. Block reuptake of norepinephrine as well as serotonin • Best known is venlafaxine (Effexor) • Have fewer side effects than SSRIs

Medication

Antidepressants ▪ Selective serotonin reuptake inhibitors ▪ Tricyclic antidepressants ▪ Monoamine oxidase inhibitors ▪ Mixed reuptake inhibitors (e.g., serotonin/norepinephrine reuptake inhibitors) • Approximately equally effective ▪ Only 50% of patients benefit ▪ Only 25% achieve normal functioning Four basic types of antidepressant medications are used to treat depressive disorders: selective-serotonin reuptake inhibitors (SSRIs), mixed reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase (MAO) inhibitors. It is important to note at the outset that there are few, if any, differences in effectiveness among the different antidepressants; approximately 50% of patients receive some benefit, with about half of the 50% coming very close to normal functioning (remission). If dropouts are excluded and only those who complete treatment are counted, the percentage of patients receiving at least some benefit increases to between 60% and 70% (American Psychiatric Association, 2010), but one thoroughgoing meta-analysis indicated that antidepressants were relatively ineffective for mild to moderate depression compared with placebo.

Anxious distress specifier.

Anxious distress specifier. The presence and severity of accompanying anxiety, whether in the form of comorbid anxiety disorders (anxiety symptoms meeting the full criteria for an anxiety disorder) or anxiety symptoms that do not meet all the criteria for disorders (Goldberg & Fawcett, 2012; Murphy & Byrne, 2012). This is perhaps the most important addition to specifiers for mood disorders in DSM-5. For all depressive and bipolar disorders, the presence of anxiety indicates a more severe condition, makes suicidal thoughts and completed suicide more likely, and predicts a poorer outcome from treatment.

DSM-5 Criteria: Premenstrual Dysphoric Disorder

At least five symptoms must be present final week before the onset of menses, improve days after onset, and minimal/absent in week post menses • Mood swings, sensitivity, etc • Irritability or anger • Depressed mood • Anxiety and tension • Decreased interests in usual activities • Difficulty concentrating' • Lethargy • Change in appetite • Problems sleeping • Feeling out of control • Physical symptoms

Persistent Depressive Disorder: An Overview

At least two years of depressive symptoms ▪ Depressed mood most of the day on more than 50% of days ▪ No more than 2 months symptom free ▪ Symptoms can persist unchanged over long periods (≥ 20 years) ▪ May include periods of more severe major depressive symptoms • Major depressive symptoms may be intermittent or last for the majority or entirety of the time period Types of PDD ▪ Mild depressive symptoms without any major depressive episodes ("with pure dysthymic syndrome") ▪ Mild depressive symptoms with additional major depressive episodes occurring intermittently (previously called "double depression") ▪ Major depressive episode lasting 2+ years ( "with persistent major depressive episode" Dysthymia - Winne the Pooh Eeyore Persistent depressive disorder (dysthymia) shares many of the symptoms of major depressive disorder but differs in its course. There may be fewer symptoms (as few as 2, see DSM-5 Table 7.4), but depression remains relatively unchanged over long periods, sometimes 20 or 30 years or more Persistent depressive disorder differs from a major depressive disorder in the number of symptoms required, but mostly it is in the chronicity. It is considered more severe, since patients with persistent depression present with higher rates of comorbidity with other mental disorders, are less responsive to treatment, and show a slower rate of improvement over time. Klein and colleagues (2006), in a 10-year prospective follow-up study, suggest that chronicity (versus nonchronicity) is the most important distinction in diagnosing depression independent of whether the symptom presentation meets criteria for a major depressive disorder (as noted above), because these two groups (chronic and nonchronic) seem different, not only in course over time but also in family history and cognitive style. Also, 22% of people suffering from persistent depression with fewer symptoms (specified as "with pure dysthymic syndrome," see below) eventually experienced a major depressive episode (Klein et al., 2006). These individuals who suffer from both major depressive episodes and persistent depression with fewer symptoms are said to have double depression. Typically, a few depressive symptoms develop first, perhaps at an early age, and then one or more major depressive episodes occur later only to revert to the underlying pattern of depression once the major depressive episode has run its course (Boland & Keller, 2009; Klein et al., 2006). Identifying this particular pattern is important because it is associated with even more severe psychopathology and a problematic future course (Boland & Keller, 2009; Klein et al., 2006; Rubio, Markowitz, Alegria, Perez-Fuentes, Liu, Lin, & Blanco, 2011).

An Integrative Theory

Biological and psychological vulnerabilities interact with stressful life events to cause depression ▪ Biological vulnerability: e.g., overactive neurobiological response to stress ▪ Psychological vulnterability: e.g., depressive cognitive style People who develop mood disorders also possess a psychological vulnerability experienced as feelings of inadequacy for coping with the difficulties confronting them as well as depressive cognitive styles. As with anxiety, we may develop this sense of control in childhood Recent research illustrates the strong associations between the genetic and generalized psychological vulnerabilities (e.g., Whisman, Johnson, & Smolen, 2011). There is also good evidence that stressful life events trigger the onset of depression in most cases in these vulnerable individuals, particularly initial episodes (Jenness, Hankin, Abela, Young, & Smollen, 2011). How do these factors interact? Current thinking is that stressful life events in vulnerable individuals activate stress hormones, which, in turn, have wide-ranging effects on neurotransmitter systems, particularly those involving serotonin, norepinephrine, and the corticotropin-releasing factor system. inally, it seems clear that factors such as interpersonal relationships (Tsai, Lucas, & Kawachi, 2015) or cognitive style (Gotlib et al., 2014) may protect us from the effects of stress and therefore from developing mood disorders. Alternatively, these factors may at least determine whether we quickly recover from these disorders or not. But remember that bipolar disorder, and particularly activation of manic episodes, seems to have a somewhat different genetic basis, as well as a different response to social support. Scientists are beginning to theorize that individuals with bipolar disorder, in addition to factors outlined so far, are also highly sensitive to the experience of life events connected with striving to reach important goals, perhaps because of an overactive brain circuit called the behavioral approach system (BAS) (Alloy & Abramson, 2010; Gruber, Johnson, Oveis, & Keltner, 2008). In these cases, stressful life events that are more positive but still stressful, such as starting a new job, or pulling all-nighters to finish an important term paper, might precipitate a manic episode in vulnerable individuals instead of a depressive episode. Individuals with bipolar disorder are also highly sensitive to disruptions in circadian rhythm. So individuals with bipolar disorder might possess brain circuits that predispose them to both depression and mania.

DSM-5 Bipolar Disorders

Bipolar I disorder ▪ Alternations between major depressive episodes and manic episodes • Bipolar II disorder ▪ Alternations between major depressive episodes and hypomanic episodes • Cyclothymic disorder ▪ Alternations between less severe depressive and hypomanic periods A milder but more chronic version of bipolar disorder is called cyclothymic disorder (Akiskal, 2009; Parker, McCraw, & Fletcher, 2012). Cyclothymic disorder is a chronic alternation of mood elevation and depression that does not reach the severity of manic or major depressive episodes. Individuals with cyclothymic disorder tend to be in one mood state or the other for years with relatively few periods of neutral (or euthymic) mood. This pattern must last for at least 2 years (1 year for children and adolescents) to meet criteria for the disorder.

Monoamine Oxidase (MAO) Inhibitors

Block monoamine oxidase • This enzyme breaks down serotonin/norepinephrine • As effective as tricyclics, with fewer side effects • Dangerous in combination with certain foods ▪ Beer, red wine, cheese cannot be consumed; patients dislike dietary restrictions ▪ Also dangerous in combination with cold medicine MAO inhibitors work differently. As their name suggests, they block the enzyme MAO that breaks down such neurotransmitters as norepinephrine and serotonin. The result is roughly equivalent to the effect of the tricyclics. Because they are not broken down, the neurotransmitters pool in the synapse, leading to a down-regulation. The MAO inhibitors seem to be as effective as the tricyclics (American Psychiatric Association, 2010), with somewhatfewer side effects. Some evidence suggests they are relatively more effective for depression with atypical features (American Psychiatric Association, 2010; Thase & Kupfer, 1996). But MAO inhibitors are used far less often because of two potentially serious consequences: Eating and drinking foods and beverages containing tyramine, such as cheese, red wine, or beer, can lead to severe hypertensive episodes and, occasionally, death. In addition, many other drugs that people take daily, such as cold medications, are dangerous and even fatal in interaction with an MAO inhibitor.

Selective Serotonin Reuptake Inhibitors

Called SSRIs • Specifically block reuptake of serotonin so more serotonin is available in the brain ▪ Fluoxetine (Prozac) is the most popular SSRI • SSRIs pose some risk of suicide particularly in teenagers • Negative side effects are common • Some evidence that SSRI use during pregnancy lowered risk for birth complications These selective-serotonin reuptake inhibitors (SSRIs) specifically block the presynaptic reuptake of serotonin. This temporarily increases levels of serotonin at the receptor site, but again the precise long-term mechanism of action is unknown, although levels of serotonin are eventually increased (Gitlin, 2009; Thase & Denko, 2008). Perhaps the best-known drug in this class is fluoxetine (Prozac). Several years ago, concerns about suicidal risks (increased thoughts, and so on)surfaced again, particularly among adolescents, and this time it looks like the concerns are justified, at least for adolescents (Baldessarini, Pompili, & Tondo, 2006; Berman, 2009; Olfson, Marcus, & Schaffer, 2006). These findings have led to warnings from the Food and Drug Administration (FDA) and other regulatory agencies around the world about these drugs. On the other hand, Gibbons, Hur, Bhaumik, and Mann (2006) found that actual suicide rates were lower in sections of the United States where prescriptions for SSRIs were higher. In addition, the SSRIs were also associated with a small but statistically significant decrease in actual suicides among adolescents compared with depressed adolescents not taking these drugs, based on a large community survey Prozac and other SSRIs have their own set of side effects, the most prominent of which are physical agitation, sexual dysfunction, low sexual desire (which is prevalent, occurring in 50% to 75% of cases), insomnia, and gastrointestinal upset.

Cyclothymic Disorder: An Overview

Chronic version of bipolar disorder • Alternating between periods of mild depressive symptoms and mild hypomanic symptoms ▪ Episodes do not meet criteria for full major depressive episode, full hypomanic episode, or full manic episode • Hypomanic or depressive mood states may persist for long periods • Must last for at least two years (one year for children and adolescents)

Additional Studies of Brain Structure and Function

Davidson (1993) and Heller and Nitschke (1997) demonstrated that depressed individuals exhibit greater right-sided anterior activation of their brains, particularly in the prefrontal cortex (and less left-sided activation and, correspondingly, less alpha wave activity) than nondepressed individuals (Davidson, Pizzagalli, Nitschke, & Putnam, 2002). Furthermore, right-sided anterior activation was also found in patients who are no longer depressed (Gotlib, Ranganath, & Rosenfeld, 1998; Tomarken & Keener, 1998), suggesting this brain function might also exist before the individual becomes depressed and represent a vulnerability to depression. Follow-up studies showed that adolescent offspring of depressed mothers tend to show this pattern, compared with offspring of nondepressed mothers Interestingly and in contrast, one recent study suggests that bipolar spectrum patients (individuals with sub-threshold swings in mood) show elevated rather than diminished relative left-frontal EEG activity and that this brain activity predicts the onset of a full bipolar I disorder (Nusslock et al., 2012). In addition to studying the prefrontal cortex and hippocampus, neuroscientists are also studying the anterior cingulate cortex and the amygdala for clues to understanding brain function in depression and finding that some areas are less active, and other areas more active, in people with depression than in normals, confirming the EEG studies mentioned above (Davidson, Pizzagalli, & Nitschke, 2009). These areas of the brain are all interconnected and seem to be associated with increased inhibition as well as deficits in pursuing desired goals, which happen to be characteristics of depression.

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder ▪ Severe temper outbursts occurring frequently, against a backdrop of angry or irritable mood ▪ Diagnosed only in children 6 to 18 ▪ Criteria for manic/hypomanic episode are not met ▪ Designed in part to combat overdiagnosis of bipolar disorder in youth More side effects in medication/ risk for bipolar Conduct/ ODD- behaviors, control Rewards work children and adolescents are being diagnosed with bipolar disorder at greatly increasing rates over the past several years. In fact, from 1995 to 2005, the diagnosis of bipolar disorder in children increased 40-fold overall and has quadrupled in U.S. community hospitals (up to 40%) Additional research demonstrated that these children with chronic and severe irritability and difficulty regulating their emotions resulting in frequent temper tantrums are at increased risk for additional depressive and anxiety disorders rather than manic episodes and that there is no evidence of excessive rates of bipolar disorder in their families, which one would expect if this condition were truly bipolar disorder.

Electroconvulsive Therapy (ECT)

Effective for medication-resistant depression • The nature of ECT ▪ Brief electrical current applied to the brain ▪ Results in temporary seizures ▪ Usually 6 to 10 outpatient treatments are required • Side effects: ▪ Short-term memory loss which is usually restored ▪ Some patients suffer long-term memory loss • Mechanism is unclear People who do not respond to drugs Multiple drug trials current administrations, patients are anesthetized to reduce discomfort and given muscle-relaxing drugs to prevent bone breakage from convulsions during seizures. Electric shock is administered directly through the brain for less than a second, producing a seizure and a series of brief convulsions that usually lasts for several minutes. In current practice, treatments are administered once every other day for a total of 6 to 10 treatments (fewer if the patient's mood returns to normal). Side effects are generally limited to short-term memory loss and confusion that disappear after a week or two, although some patients may have long-term memory problems. For severely depressed inpatients with psychotic features, controlled studies indicate that approximately 50% of those not responding to medication will benefit. Continued treatment with medication or psychotherapy is then necessary because the relapse rate approaches 60% or higher Thus, follow-up treatment with antidepressant drugs or psychological treatments is necessary, but relapse is still high. Nevertheless, it may not be in the best interest of psychotically depressed and acutely suicidal inpatients to wait 3 to 6 weeks to determine whether a drug or psychological treatment is working; in these cases, immediate ECT may be appropriate. We do not really know why ECT works. Repeated seizures induce massive functional and perhaps structural changes in the brain, which seems to be therapeutic. There is some evidence that ECT increases levels of serotonin, blocks stress hormones, and promotes neurogenesis in the hippocampus.

Manic Episode

Elevated, expansive mood for at least one week • Examples of symptoms: ▪ Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors • Impairment in normal functioning They become extraordinarily active (hyperactive), require little sleep, and may develop grandiose plans, believing they can accomplish anything they desire. DSM-5 highlights this feature by adding "persistently increased goal-directed activity or energy" to the "A" criteria (see DSM-5 Table 7.2; American Psychiatric Association, 2013). Speech is typically rapid and may become incoherent, because the individual is attempting to express so many exciting ideas at once; this feature is typically referred to as flight of ideas. DSM-5 criteria for a manic episode require a duration of only 1 week, less if the episode is severe enough to require hospitalization. Hospitalization could occur, for example, if the individual was engaging in a self-destructive buying spree, charging thousands of dollars in the expectation of making a million dollars the next day. Irritability is often part of a manic episode, usually near the end. Paradoxically, being anxious or depressed is also commonly part of mania, as described later. The duration of an untreated manic episode is typically 3 to 4 months

Major Depressive Episode

Extremely depressed mood and/or loss of pleasure (anhedonia) ▪ Lasts most of the day, nearly every day, for at least two weeks • At least five additional physical or cognitive symptoms: ▪ E.g., indecisiveness, feelings of worthlessness, fatigue, appetite change, restlessness or feeling slowed down, sleep disturbance irritable mood in children & adolescents Anhedonia (loss of energy and inability to engage in pleasurable activities or have any "fun") is more characteristic of these severe episodes of depression than are, for example, reports of sadness or distress (Pizzagalli, 2014). Nor does the tendency to cry, which occurs equally in depressed and nondepressed individuals (mostly women in both cases) reflect severity—or even the presence of a depressive episode (Vingerhoets, Rottenberg, Cevaal, & Nelson, 2007). This anhedonia reflects that these episodes represent a state of low positive affect and not just high negative affect (Brown & Barlow, 2009). The duration of a major depressive episode, if untreated, is approximately 4 to 9 months

Familial and Genetic Influences

Family studies • Risk is higher if relative has a mood disorder • Relatives of bipolar probands are more likely to have unipolar depression Twin studies ▪ Concordance rates are high in identical twins • Two to three times more likely to present with mood disorders than a fraternal twin of a depressed co-twin ▪ Severe mood disorders have a strong genetic contribution ▪ Heritability rates are higher for females compared to males ▪ Some genetic factors confer risk for both anxiety and depression We have found that, despite wide variability, the rate in relatives of probands with mood disorders is consistently about 2 to 3 times greater than in relatives of controls who don't have mood disorders (Lau & Eley, 2010; Klein, Lewinsohn, Rohde, Seeley, & Durbin, 2002; Levinson, 2009). Increasing severity, recurrence of major depression, and earlier age of onset in the proband is associated with the highest rates of depression in relatives In a large meta-analysis of twin studies, Sullivan et al. (2000) estimated the heritability of depression to be 37%. Shared environmental factors have little influence, whereas 63% of the variance in depression can be attributed to non-shared environmental factors. stimates of heritability in women ranged from 36% to 44%, consistent with other studies. But estimates for men were lower and ranged from 18% to 24%. These results mostly agree with an important study of men in the United States by Lyons and colleagues (1998). The authors conclude that environmental events play a larger role in causing depression in men than in women. Note from the studies just described that bipolar disorder confers an increased risk of developing some mood disorder in close relatives, but not necessarily bipolar disorder. This conclusion supports an assumption noted previously that bipolar disorder may simply be a more severe variant of mood disorders rather than a fundamentally different disorder. Then again, of identical twins both having (concordant for) a mood disorder, 80% are also concordant for polarity. McGuffin and colleagues (2003) conclude that both points are partially correct. Basically, they found that the genetic contributions to depression in both disorders are the same or similar but that the genetics of mania are distinct from depression. Thus, individuals with bipolar disorder are genetically susceptible to depression and independently genetically susceptible to mania. Evidence supports the assumption of a close relationship among depression, anxiety, and panic (as well as other emotional disorders). For example, data from family studies indicate that the more signs and symptoms of anxiety and depression there are in a given patient, the greater the rate of anxiety, depression, or both in first-degree relatives and children (Hudson et al., 2003; Leyfer & Brown, 2011). These findings again suggest that, with the possible exception of mania, the biological vulnerability for mood disorders may not be specific to that disorder but may reflect a more general predisposition to anxiety or mood disorders, or, more likely to a basic temperament underlying all emotional disorders, such as neuroticism (Barlow et al., 2013).

Interpersonal psychotherapy

Focus: Improving problematic relationships Interpersonal psychotherapy (IPT) (Bleiberg & Markowitz, 2014; Klerman, Weissman, Rounsaville, & Chevron, 1984; Weissman, 1995) focuses on resolving problems in existing relationships and learning to form important new interpersonal relationships. Like cognitive-behavioral approaches, IPT is highly structured and seldom takes longer than 15 to 20 sessions, usually scheduled once a week (Cuijpers et al., 2011). After identifying life stressors that seem to precipitate the depression, the therapist and patient work collaboratively on the patient's current interpersonal problems. Typically, these include one or more of four interpersonal issues: dealing with interpersonal role disputes, such as marital conflict; adjusting to the loss of a relationship, such as grief over the death of a loved one; acquiring new relationships, such as getting married or establishing professional relationships; and identifying and correcting deficits in social skills that prevent the person from initiating or maintaining important relationships. Studies comparing the results of cognitive therapy and IPT with those of antidepressant drugs and other control conditions have found that psychological approaches and medication are equally effective immediately following treatment, and all treatments are more effective than placebo conditions, brief psychodynamic treatments, or other appropriate control conditions for both major depressive disorder and persistent depressive disorder

Prevention

Gillham and colleagues (2012) taught cognitive and social problem-solving techniques to more than 400 middle school children ages 10 to 15 who were at risk for depression because of negative thinking styles. Compared with children in a matched no-treatment control group, the prevention group reported fewer depressive symptoms during follow up. Seligman, Schulman, DeRubeis, and Hollon (1999) conducted a similar course for university students who were also at risk for depression based on a pessimistic cognitive style. nother recent study also demonstrated that meeting in an integrated fashion with families that included parents who had a history of depression and included their 9- to 15-year-old children (who were at risk because of their parents' depression) was successful in preventing depression in these families during a follow-up period (Compas et al., 2009). Additional studies have indicated that preventing depression is possible in older adults in primary care settings (van't Veer-Tazelaar et al., 2009) and also in poststroke patients, a particularly high-risk group (Robinson et al., 2008; Reynolds, 2009). A recent review suggests that CBT, delivered during the acute phase, appears to have an enduring effect that protects some patients against relapse and others from recurrence following treatment termination. Furthermore, continuation CBT seems to reduce the risk for relapse, and maintenance CBT appears to reduce the risk for recurrence