Week 20 Reading 1

Depressive Disorders & Bipolar and Related Disorders

Key terms:

 Anhedonia: Loss of interest or pleasure in activities one previously found enjoyable or

rewarding.
 Grandiosity: Inflated self-esteem or an exaggerated sense of self-importance and self-worth
(e.g., believing one has special powers or superior abilities).
 Socioeconomic status (SES): A person’s economic and social position based on income,
education, and occupation.
 Early adversity: Single or multiple acute or chronic stressful events, which may be biological
or psychological in nature (e.g., poverty, abuse, childhood illness or injury), occurring during
childhood and resulting in a biological and/or psychological stress response.
 Chronic stress: Discrete or related problematic events and conditions which persist over
time and result in prolonged activation of the biological and/or psychological stress
response (e.g., unemployment, ongoing health difficulties, marital discord).
 Attributional style: The tendency by which a person infers the cause or meaning of
behaviors or events.
 Social zeitgeber: Zeitgeber is German for “time giver.” Social zeitgebers are environmental
cues, such as meal times and interactions with other people, that entrain biological rhythms
and thus sleep-wake cycle regularity.
 Hypersomnia: Excessive daytime sleepiness, including difficulty staying awake or napping, or
prolonged sleep episodes.
 Psychomotor agitation: Increased motor activity associated with restlessness, including
physical actions (e.g., fidgeting, pacing, feet tapping, handwringing).
 Psychomotor retardation: A slowing of physical activities in which routine activities (e.g.,
eating, brushing teeth) are performed in an unusually slow manner.
 Suicidal ideation: Recurring thoughts about suicide, including considering or planning for
suicide, or preoccupation with suicide.

Introduction:
 Everyone feels down or euphoric from time to time, but this is different from having a mood
disorder such as major depressive disorder or bipolar disorder.
 Mood disorders are:
o extended periods of depressed, euphoric, or irritable moods
o that in combination with other symptoms cause the person significant distress and
interfere with his or her daily life
o often resulting in social and occupational difficulties.
Describe the diagnostic criteria for mood disorders:

Mood Episodes:
 Major Depressive Episode:
o refers to symptoms that:
 co-occur for at least two weeks
 and cause significant distress or impairment in functioning, such as
interfering with work, school, or relationships.
o Core symptoms include feeling down or depressed and/or experiencing anhedonia
—loss of interest or pleasure in things that one typically enjoys.
o What is depressed mood?
 Emptiness
 Hopelessness
 Irritability
 Guilt
 Pessimism
 Emotional numbness
o According to the DSM-5, the criteria for an MDE require five or more of the
following nine symptoms, including one or both of the first two symptoms, for
most of the day, nearly every day:
1. Depressed mood
2. Anhedonia: diminished interest or pleasure in almost all activities
3. Weight change (loss or gain) or an increase or decrease in appetite
4. Sleep disturbance: insomnia or hypersomnia
5. Psychomotor changes: e.g., slowing of thinking, movement
6. Loss of energy
7. Feeling worthless or excessive or inappropriate guilt
8. Diminished ability to concentrate or indecisiveness
9. recurrent thoughts of death, suicidal ideation, or a suicide attempt
o These symptoms cannot be caused by physiological effects of a substance or a
general medical condition (e.g., hypothyroidism).
 Manic or Hypomanic Episode:
o The core criterion for a manic or hypomanic episode is
 a distinct period of abnormally and persistently euphoric, expansive, or
irritable mood (markedly changed behaviour).
 and persistently increased goal-directed activity or energy.
o The mood disturbance must be present for one week or longer in mania (unless
hospitalization is required) or four days or longer in hypomania.
o Concurrently, at least three of the following symptoms must be present in the
context of euphoric mood (or at least four in the context of irritable mood):
1. inflated self-esteem or grandiosity
2. increased goal-directed activity or psychomotor agitation
3. reduced need for sleep
4. racing thoughts or flight of ideas
 5. distractibility
6. increased talkativeness
7. excessive involvement in risky behaviors
o Manic episodes are distinguished from hypomanic episodes by their duration and
associated impairment:
 whereas manic episodes must last one week and are defined by a significant
impairment in functioning
 hypomanic episodes are shorter and not necessarily accompanied by
impairment in functioning

Mood Disorders:
 Unipolar Mood Disorders:
o Two major types of unipolar disorders described by the DSM-5 are major depressive
disorder and persistent depressive disorder (PDD; dysthymia or chronic major
depression).
o MDD (AKA Clinical Depression) is defined by:
 one or more MDEs
 but no history of manic or hypomanic episodes.
 MDEs are separated by at least 2 months
 these symptoms need to cause significant distress or impairment and cannot
be due to the effects of a substance or a general medical condition.
o Criteria for PDD are:
 feeling depressed most of the day for more days than not, for at least two
years.
 At least two of the following symptoms are also required to meet criteria for
PDD:
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
o Like MDD, these symptoms need to cause significant distress or impairment and
cannot be due to the effects of a substance or a general medical condition.
o To meet criteria for PDD, a person cannot be without symptoms for more than two
months at a time.
o PDD has overlapping symptoms with MDD. If someone meets criteria for an MDE
during a PDD episode, the person will receive diagnoses of PDD and MDD.
 Bipolar Mood Disorders:
o Three major types of BDs are described by the DSM-5:
 Bipolar I Disorder (BD I), which was previously known as manic-depression:
 Is characterized by a single (or recurrent) manic episode.
 A depressive episode is not necessary but commonly present for the
diagnosis of BD I.
 Bipolar II Disorder is characterized by:
 single (or recurrent) hypomanic episodes and depressive episodes.
 Less intense highs but with definite depressive episodes
 Another type of BD is cyclothymic disorder:
 characterized by numerous and alternating periods of hypomania
and depression, lasting at least two years.
 To qualify for cyclothymic disorder:
o the periods of depression cannot meet full diagnostic criteria
for an MDE
o the person must experience symptoms at least half the time
with no more than two consecutive symptom-free months
(less than two months between episodes)
o and the symptoms must cause significant distress or
impairment.

Understand age, gender, and ethnic differences in prevalence rates of mood disorders:

Depressive Disorders:
 Prevalence:
o Lifetime prevalence rate for MDD is 16.6%. This means that nearly one in five
Americans will meet the criteria for MDD during their lifetime.
o Age: Prevalence of MDD among older adults is much lower than it is for younger
cohorts (mid 20s)
o Gender: Women experience two to three times higher rates of MDD than do men.
This gender difference emerges during puberty. Before puberty, boys exhibit similar
or higher prevalence rates of MDD than do girls.
 o Socioeconomic status: MDD is inversely correlated with socioeconomic status (SES),
a person’s economic and social position based on income, education, and
occupation. Higher prevalence rates of MDD are associated with lower SES
o Race: Native Americans and European Americans had a higher prevalence rate of
MDD than did African Americans and Hispanic Americans
o Depression is not limited to industrialized or western cultures
 Onset:
o Although the onset of MDD can occur at any time throughout the lifespan, the
average age of onset is mid-20s, with the age of onset decreasing with people born
more recently
o An earlier age of onset predicts a worse course.
 The duration of MDEs varies widely. Recovery begins within three months for 40% of
people with MDD and within 12 months for 80%
 MDD tends to be a recurrent disorder with about 40%–50% of those who experience one
MDE experiencing a second MDE
 About 5%–10% of people who experience an MDE will later experience a manic episode
(APA, 2000), thus no longer meeting criteria for MDD but instead meeting them for BD I.
 Highly comorbid:Diagnoses of other disorders across the lifetime are common for people
with MDD:
o 59% experience an anxiety disorder
o 32% experience an impulse control disorder
o 24% experience a substance use disorder

Bipolar Disorders:
 Prevalence:
o The lifetime prevalence rate of bipolar spectrum disorders in the general U.S.
population is estimated at approximately 4.4%, with BD I constituting about 1% of
this rate
o Worldwide prevalence of BD at 2.4%, with BD I constituting 0.6% of this rate
o Whereas the United States had the highest lifetime prevalence (4.4%), India had the
lowest (0.1%)
o Variation in prevalence rates was not necessarily related to SES, as in the case of
Japan, a high-income country with a very low prevalence rate of BD
o Gender:
 BD I: Women = Men
 BD II: Women > Men
 Cyclothymic: Women = Men
o Age: The prevalence of BD is substantially lower in older adults compared with
younger adults (1% vs. 4%)
o Race: available reports suggest rates of BD among European Americans are similar to
those found among African Americans and Hispanic Americans
 o Onset:
 As with MDD, adolescence is known to be a significant risk period for BD;
mood symptoms start by adolescence in roughly half of BD cases:
 BD I: 14-21 yrs
 BD II: 18-29
 Cyclothymic: adolescence - early adulthood
 those diagnosed with BD prior to adulthood experience a more pernicious
course of illness relative to those with adult onset, including more episode
recurrence, higher rates of suicidality, and profound social, occupational, and
economic repercussions
 Approximately 65% of people with BD meet diagnostic criteria for at least one additional
psychiatric disorder, most commonly anxiety disorders and substance use disorders
 The co-occurrence of BD with other psychiatric disorders is associated with poorer illness
course, including higher rates of suicidality

Identify common risk factors for mood disorders:

Depressive Disorders:
 Genetic factors:
o Research across family and twin studies has provided support that genetic factors
are implicated in the development of MDD.
o The mode of inheritance is not fully understood although no single genetic variation
has been found to increase the risk of MDD significantly.
 Environmental stressors:
o Stressful life events:
 Those that have long-term consequences and involve loss of a significant
relationship (e.g., divorce) or economic stability (e.g., unemployment) are
strongly related to depression
 Stressful life events are more likely to predict the first MDE than subsequent
episodes
 In contrast, minor events may play a larger role in subsequent episodes than
the initial episodes
o experiencing early adversity (e.g., childhood abuse or neglect)
o chronic stress (e.g., poverty)
o interpersonal factors (e.g., marital dissatisfaction)
 Brain Function:
o Much research, particularly brain imagining research using functional magnetic
resonance imaging (fMRI), has centered on examining neural circuitry.
o A meta-analysis of neuroimaging studies showed that when viewing negative stimuli
(e.g., picture of an angry face, picture of a car accident), participants with MDD have
greater activation in brain regions involved in stress response and reduced
activation of brain regions involved in positively motivated behaviors
 People’s attributional styles or their general ways of thinking, interpreting, and recalling
information have also been examined in the etiology of MDD:
o People with a pessimistic attributional style tend to make internal (versus external),
global (versus specific), and stable (versus unstable) attributions to negative events,
serving as a vulnerability to developing MDD
o For example, someone who when he fails an exam thinks that it was his fault
(internal), that he is stupid (global), and that he will always do poorly (stable) has a
pessimistic attribution style.

Bipolar Disorders:
 Genetic factors:
o There is compelling evidence for biological causes of BD, which is known to be highly
heritable (transmissible from parent to offspring): 44-90%
o The triggers that determine how and when this genetic vulnerability is expressed are
not yet understood; however, there is evidence to suggest that psychosocial triggers
may play an important role in BD risk.
 Brain Function:
o Many of the studies using fMRI techniques to characterize BD have focused on the
processing of emotional stimuli based on the idea that BD is fundamentally a
disorder of emotion.
o Findings show that regions of the brain thought to be involved in emotional
processing and regulation are activated differently in people with BD relative to
healthy controls
 Environmental stressors:
o Severe stressors (e.g., loss of a significant relationship), can adversely impact the
course of BD. People with BD have substantially increased risk of relapse and suffer
more depressive symptoms following a severe life stressor
o Positive life events can also adversely impact the course of BD. People with BD suffer
more manic symptoms after life events involving attainment of a desired goal
 Social zeitgeber theory:
o According to social zeitgeber (time giver) theory, stressors that disrupt sleep, or that
disrupt the daily routines that entrain the biological clock (e.g., meal times) can
trigger episode relapse.
o studies have shown that life events that involve a disruption in sleep and daily
routines, such as overnight travel, can increase bipolar symptoms in people with BD

Know effective treatments of mood disorders:

Depressive Disorders:
 Antidepressants:
o They target one or more of the neurotransmitters implicated in depression.
o Monoamine oxidase inhibitors (MAOIs):
 The earliest antidepressant medications
  MAOIs inhibit monoamine oxidase, an enzyme involved in deactivating
dopamine, norepinephrine, and serotonin.
 Serious side effects: Patients taking MAOIs may develop dangerously high
blood pressure if they take certain drugs (e.g., antihistamines) or eat foods
containing tyramine, an amino acid commonly found in foods such as aged
cheeses, wine, and soy sauce.
o Tricyclics:
 the second-oldest class of antidepressant medications:
 block the reabsorption of norepinephrine, serotonin, or dopamine at
synapses, resulting in their increased availability.
 Tricyclics are most effective for treating vegetative (e.g. change in sleeping
habits and appetite) and somatic symptoms of depression.
 Serious side effects: the most concerning of which is being cardiotoxic.
o Selective serotonin reuptake inhibitors (SSRIs; e.g., Fluoxetine) and serotonin and
norepinephrine reuptake inhibitors (SNRIs; e.g., Duloxetine):
 First line treatment choice for DD
 are the most recently introduced antidepressant medications.
 SSRIs, the most commonly prescribed antidepressant medication, block the
reabsorption of serotonin
 SNRIs block the reabsorption of serotonin and norepinephrine.
 SSRIs and SNRIs have fewer serious side effects than do MAOIs and
tricyclics:
 they are less cardiotoxic
 less lethal in overdose
 produce fewer cognitive impairments.
 They are not, however, without their own side effects, which include:
 difficulty having orgasms
 gastrointestinal issues
 insomnia.
o Anti-depressant medications may not work equally for all people. This approach to
treatment often involves experimentation with several medications and dosages, and
may be more effective when paired with physical exercise and psychotherapy.
 Other biological treatments:
o Electroconvulsive therapy (ECT):
 involves inducing a seizure after a patient takes muscle relaxants and is
under general anesthesia.
 is viable treatment for patients with severe depression or who show
resistance to antidepressants
 the mechanisms through which it works remain unknown.
 A common side effect is confusion and memory loss, usually short-term
o Transcranial magnetic stimulation (TMS):
 Repetitive TMS is a noninvasive technique administered while a patient is
awake.
  Brief pulsating magnetic fields are delivered to the mood-regulatory regions
of the prefrontal cortex
 TMS has fewer side effects than ECT (headache or rarely seizure)
o Deep brain stimulation:
 involves implanting an electrode in the brain.
 The electrode is connected to an implanted neurostimulator, which
electrically stimulates that particular brain region.
 Although there is some evidence of its effectiveness additional research is
needed.
 Psychosocial treatments: Time limited (12-20 weeks in MDD)
o Behavior therapies: focus on increasing the frequency and quality of experiences
that are pleasant or help the patient achieve mastery.
o Cognitive therapies: primarily focus on helping patients identify and change
distorted automatic thoughts and assumptions.
o Interpersonal Therapy for Depression: focuses largely on improving interpersonal
relationships by targeting problem areas, specifically unresolved grief, interpersonal
role disputes, role transitions, and interpersonal deficits.
o Short-Term Psychodynamic Therapy for Depression: focuses on a limited number of
important issues, and the therapist tends to be more actively involved than in more
traditional psychodynamic therapy.

Bipolar Disorders:
 Lithium:
o first line treatment choice for BD
o This is because SSRIs and SNRIs have the potential to induce mania or hypomania in
patients with BD
o acts on several neurotransmitter systems in the brain including:
 reduction of excitatory (dopamine and glutamate) neurotransmission
 increasing of inhibitory (GABA) neurotransmission
o side effects can make lithium treatment difficult for patients to tolerate (increase risk
of noncompliance):
 impaired cognitive function
 physical symptoms: such as nausea, tremor, weight gain, and fatigue
 Anticonvulsant medications (e.g., carbamazepine, valproate):
o also commonly used to treat patients with BD
o either alone or in conjunction with lithium
 Adjunctive treatment options:
o Interpersonal and social rhythm therapy (IPSRT):
 is a psychosocial intervention focused on addressing the mechanism of action
posited in social zeitgeber theory to predispose patients who have BD to
relapse, namely sleep disruption.
 IPSRT aims to increase rhythmicity of patients’ lives and encourage vigilance
in maintaining a stable rhythm.
 The therapist and patient work to develop and maintain a healthy balance of
activity and stimulation such that the patient does not become overly active
(e.g., by taking on too many projects) or inactive (e.g., by avoiding social
contact).
 patients who received this treatment show reduced risk of episode
recurrence and are more likely to remain well