Mood Disorders: Depression, Mania, &

Bipolar Disorder

By:- firoz qureshiDept. psychiatric nursing

What is Mood?

“Mood is a a conscious state of mind or predominant emotion”

Webster’s Dictionary

What is a Mood Disorder?

Involves disabling disturbances in emotions that are markedly different from normal functioning

Can also include cognitive & behavioral disturbances

Generally occurs in discrete episodes– Depression – extreme sadness – Mania – extreme elation and irritability

Types of Mood Disorders

Main Distinction: unipolar or bipolar– Unipolar: only one end of the emotion spectrum

Major Depressive Episode Manic Episode

– Bipolar: cycling between both ends of the emotion spectrum

Bipolar Disorder

Other Disorders– Dysthymia: mild, chronic form of depression – Cyclothymia: similar to bipolar, but a more mild

form of mania (hypomania)

Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder

Manic Episode: DSM Criteria

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:(1) inflated self-esteem or grandiosity(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)(3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing(5) distractibility (i.e., attention too easily drawn to unimportant stimuli)(6) increase in goal-directed activity or psychomotor agitation(7) excessive involvement in pleasurable activities that have a high potential for painful consequences

Manic Episode Rule-Outs

do not meet criteria for a Mixed Episode – Mixed episode = both manic and depressed nearly everyday for

at least one week

marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder

Bipolar I 1 or more manic episodes; may have

had past depressive episodes or not Lifetime Prevalence: about 1%; equal in

men and women Course and Prognosis: poorer prognosis

than MDD– 45% have one more episode – only 50-60% achieve control over Sx with lithium– 40% develop a chronic disorder

Bipolar II recurrent major depressive episodes

with hypomanic episodes– Hypomania - All the criteria of a Manic

episode except criterion C (marked impairment)

– NOT full-blown manic episodes, if an individual does experience a manic episode, they are then diagnosed with Bipolar I Disorder

matter of differential diagnosis

Bipolar Disorder

Bipolar I Alternation of

full manic and depressive episodes

Average onset is 18 years

Tends to be chronic

High risk for suicide

Bipolar II Alternation of

Major Depression with hypomania

Average onset is 22 years

Tends to be chronic

10% progess to full biploar I disorder

CyclothymiaA. For at least two years (one year for children

and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depression

B. During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a time

C. No evidence of MDD or Manic episode during the first two years of disturbance

D. No psychotic disorderE. No organic cause

Mania Etiology better-suited for the biological model

– not normally distributed in the population – Symptoms are very marked and severe

not necessarily precipitated by a positive life event & can override negative events– further evidence in favor of diathesis

Familial Pattern seen

Twin and adoption studies

What Does Mania Look Like?

Client 1: Mary

Depressive Disorders Major Depressive Disorder (single,

recurrent) [Major Depressive Disorder:

Postpartum onset]** Dysthymic Disorder Double Depression Postpartum depression as a

specifier

What Does Depression Look Like?

– Sadness– Suicidal Thoughts– Tiredness– Boredom– Unwilling to get out – Insomnia

Depressive Episode/Disorder:

DSM Criteria Five or more of the following during the same 2-week

period that represent a change from usual functioning including either (1) depressed mood or (2) loss of interest.

Sad, depressed mood, most of the day, nearly every day for two weeks

Loss of interest and pleasure in usual activities Difficulties sleeping Shift in activity level Changes in appetite and weight loss/gain Loss of energy, fatigue Negative self-concept, self-blame, guilt,

worthlessness Difficulty concentrating Recurrent thoughts of death or suicide

Depression Diagnosis Rule-Outs

The symptoms do not meet criteria for a Mixed Episode

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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).

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Major Depression

MDD, Single episode

Absence of mania or hypomania

MDD, Recurrent

2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood

Dysthymic Disorder: SymptomsA. Depressed/irritable moodB. Presence of two of the following: Appetite disturbance Sleep disturbance Low energy/fatigue Poor concentration of difficulties making decision Feelings of hopelessnessC. Present for two year period (one year in children and

adolescents)D. No evidence of a Major Depressive Epidsode during

the first two years (one year for children)E. No manic or hypomanic episodeF. No chronic psychotic disorderG. Not related to organic factors

“Double Depression” Not a diagnosis Meet diagnostic criteria for both

MDD and Dysthymic Disorder

Prevalence Point prevalence is the

percentage of the population who have the disorder at a particular time or over a given period of time.

Lifetime prevalence is the percentage of individuals who have ever had a specific disorder at any time.

Facts About Depression

Major depression is the single most common psychiatric disorder in the U.S.

The point prevalence rate over a 1-year period is 8% for men and 13% for women.

Lifetime prevalence rate is 12.7% for men and 21.3% for women.

In addition, depression is the most common factor leading to suicide.

What Does Depression Look Like?

Client 1: Mary Client 2: Barbara Client 3: Evelyn

Video Reactions? What symptoms of depression did

you notice in these clients?

Any evidence of suicidal thoughts?

Which patient might be more likely to commit suicide? Why?

Etiology: Biological

Genetic Factors– Family, twin, and adoption studies suggest

that depression in hereditary – More severe the depression in an

individual, more likely that relative have depression as well

– MDD concordance: 40% MZ, 10% DZ– Mania concordance: 75% MZ, 25% DZ– Severity of disorder is due to strength of

genetic loading

Etiology: Biological cont. Adoption studies

– More mood disorders occur in the biological relatives of those with mood disorders

– both unipolar and bipolar disorders– severity linked to the strength of the

genetic loading

Etiology: Biological Con’t

Neurochemical Factors– Neurotransmitters

Norepinephrine Serotonin Dopamine

– Not clear what processes are dysfunctional (production, reuptake, chemical breakdown, etc.)

– Neuroendocrine changes Hypothyroidisim

Research on Neurotransmitters

norepinephrine & serotonin– Implicated in mania and depression

effectiveness of antidepressants – most drugs in psychiatry discovered by

accident Not as simple a relationship as

previously thought– E.g. TCA and MAOI drugs

Permissive hypothesis

Beck’s Cognitive Theory of Depression

distortions of reality & depressogenic cognitions result in depression

schema filters and organizes experiences to store beliefs and knowledge about ourselves

cognitive triad of negative schemas– negative view of the self, the world, and

the future

Cognitive Theory Con’t negative automatic thoughts

– further bias that individuals’ view of himself, the world, and the future

– e.g., arbitrary inference, selective abstraction, overgeneralization, magnification, etc.

thoughts focused on experiences of loss and failure

research supports the presence of distorted, automatic cognitions – the causal relationship of these factors not

established

Helplessness/Hopelessness Model

Seligman’s learned helplessness model started as a conditioning model with dogs

those who were exposed to uncontrollable aversive situations would develop depression that was rooted in feelings of helplessness

Attributional Model Abramson - Attribution of lack of control over

stress leads to anxiety and depression

Cognitive distortions affect the interpretation of causes of events in people’s lives.

biased attributional style (i.e., a cognitive style regarding beliefs about the causes of events) characterized by internal, stable, and global attributions.

Seligman and BeckSeligmanAttributions are: Internal Stable Global

I am inadequate (internal) at everything (global) and I always will be (stable).

“Dark glasses about why things are bad”

Interpretation (theory)

BeckNegative interpretations

about: Themselves Immediate world (their

place) Future (their place)

I am not good at school (self). I hate this campus (world). Things are not going to go well in college (future).

“Dark glasses about what is going on”

Description

Attributional Model Con’t

Internal - attribute negative events to own failings

Stable - belief that causes of negative events remain constant

Global - assume causes of negative events have broad and general effects

research supports the hopelessness model – but cannot establish causal relationship

Major Depression: Social and Cultural Factors Stressful life events Social support (marital

relationship) (see chart) Gender Culture (see chart)

Marital Status and MDDPercentage w/MDD

2.1 2.12.8

6.3

0

1

2

3

4

5

6

7

Married Widowed Never M. M/D/W

MarriedWidowedNever M. M/D/W

Ethnicity and Prevalence of MDDPercentage by Ethnicity

3.1

4.45.1 4.9

0

1

2

3

4

5

6

Af. Am Latina White Average

Af. AmLatinaWhiteAverage

Gender Differences in Depression

Dr. Susan Nolen-Hoeksema Women diagnosed twice as often as

men difference not evident in childhood

– boys and girls are just as likely to experience depression

– Changes in preteen years What factors may be involved in the

development of these differences?

Diathesis-Stress Model

Neither biological nor environmental and personal factors alone can produce depression

a biological vulnerability (or diathesis) interacts with life stressors to produce depression – For example, a neurotransmitter

dysfunction may interact with life stressors (e.g., death of a loved one) to produce depression

Diathesis-Stress Example

No Life Event Life Event

Depr

essio

n

Low NE

Normal NE

Comorbidity with Anxiety distinguishing depression from anxiety difficult Watson & Clark: tripartite model

– Negative affectivity (NA) - pervasive individual differences in negative emotionality and self-concept

Common to anxiety & depression

– Anhedonia - lack of experiencing pleasure specific to depression

– Anxious arousal - physiological symptoms of anxiety specific to anxiety disorders

Psychological Treatments for Depression

Psychodynamic Therapies

Cognitive-Behavioral Therapies– Beck Cognitive Therapy– Social Skills Training– Behavioral Activation

Interpersonal Therapy

Cognitive Therapy

Procedures16 weeks of treatmentExtensive Assessment:

Placebo & Clinical Management

Depression Collaborative Research ProgramInterpersonal

Psychotherapy

T

Treatment Groups

Outcome MeasuresDepressive SymptomsOverall symptomotology and life functioningFunctioning in treatment specific domains

Results:Post-Treatment

• Equivalent success in three active treatments over placebo

• Medication was faster • IPT better than CBT for

more severely depressed patients

• Particular treatments effected change in expected domains

ResultsFollow-up-18 months

• Equivalent success in three active treatments• Only 20 to 30% of recovered patients were still

well• Patients in IPT report more satisfaction with

treatment• IPT and CBT patients more likely to report that

treatment affected capacity to establish and maintain relationships and to understand source of their depression

MedicationImiprimine

Many Controversial Issues

Biological Therapies for Depression

Drug Therapies– Tricyclics– Selective serotonin reuptake

inhibitors– Monoamine oxidase inhibitors

Electroconvulsive Therapy

Mood Disorders: PrevalenceDisordersMajor

DepressionDysthymiaBipolar IBipolar II

MDD (Postpartum)

Prevalence4.9%3.2%0.8%0.5

13%

Suicide 8th leading cause of death in the

U.S. Overwhelmingly white

phenomena Suicide rates also quite high in

Native American Rate of suicide is increasing in

adolescents and elderly Males are more likely to commit

suicide Females are more likely to

attempt suicide (except China)

5 Myths and Facts About SuicideMyth #1: People who

talk about killing themselves rarely commit suicide.

Fact: Most people

who commit suicide have given some verbal clues or warnings of their intentions

5 Myths and Facts About SuicideMyth #2: The suicidal

person wants to die and feels there is no turning back.

Fact: Suicidal people

are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems.

5 Myths and Facts About SuicideMyth # 3: If you ask

someone about their suicidal intentions, you will only encourage them to kill themselves.

Fact: The opposite is

true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment.

5 Myths and Facts About SuicideMyth # 4: All suicidal

people are deeply depressed.

Fact: Although depression

is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.

5 Myths and Facts About SuicideMyths # 5: Suicidal people

rarely seek medical attention.

Fact: 75% of suicidal

individuals will visit a physician within the month before they kill themselves.

Sociodemographic Risk Factors Male > 60 years Widowed or Divorced White or Native American Living alone (social isolation) Unemployed (financial difficulties) Recent adverse life events Chronic Illness

Clinical Risk Factors Previous Attempts Clinical depression or schizophrenia Substance Abuse Feelings of hopelessness Severe anxiety, particularly with

depression Severe loss of interest in usual

activities Impaired thought process Impulsivity

Assessing Risk and Planning InterventionRiskLevel

Specific

Plan

Risk Factors

Severity

Intent

Interven.

Low No Few None Safety Plan

Mod. VaguePlan/low

lethal

Increased None Safety Plan

Severe Specificlethal plan

Increased None Safety PlanRemove

Lethal ItemsExtreme Specific

lethal planIncreased Intent to die Safety Plan

Remove Lethal ItemsHospitalize

Commonalities of Suicide

(Schneiderman, 1985)1. purpose is to seek a solution. 2. goal is the cessation of consciousness (not

death). 3. stimulus is intolerable psychological pain. 4. stressor is frustrated psychological needs. 5. emotion is hopelessness-helplessness. 6. cognitive state is ambivalence. 7. perceptual state is constriction. 8. action is egression. 9. interpersonal act is communication of intention. 10. consistency is with lifelong coping patterns.

Clinical Considerations of Suicide AssessmentFor those who are reluctant to

assess suicide:

Asking questions may feel intrusive but not asking has dangerous consequences

A calm and genuinely concerned approach is effective

Suicide:Treatment Problem-solving Cognitive behavioral therapy Coping skills Stress reduction

Postpartum Depression

Burden In the United States, depression is the

leading cause of non-obstetric hospitalizations among women aged 18-44.

In the year 2000, 205,000 women aged 18-44 were discharged with a diagnosis of depression.

Seven percent of all hospitalizations among young women were for depression.

Perinatal Depression: Prevalence

Pregnancy PostpartumKumar & Robeson 1984

13.4% 14.9%

Watson & Elliott 1984

9.4% 12.0%

O’Hara et al., 1984 9.0% 12.0%

Cooper et al. 1988 6.0% 8.7%

O’Hara et al., 1990 7.7% 10.4%

Evans et al., 2001 13.6% 9.2%

Postpartum Blues Most common, 50-

80% Relatively brief

– Few hours to several days

Onset usually in first week to 10 days PP

Typically remit spontaneously– May represent the

initial stages of PPD/PPP

Typical Blues Symptoms Low Mood Mood Lability Insomnia

Anxiety Crying Irritability

Postpartum Psychosis

Rare: 1/1000 postpartum women

Hallucinations and/or Delusions

Risk Factors: History Bipolar

Affective Disorder/Psychosis

Family history of psychosis

Having first child

Aggressive intervention absolutely necessary

Postpartum Psychosis

Usually Begins Within 90 Days Postpartum

Length is Quite Variable Prevalence: 1/500 to 1/1000 Family history of bipolar disorder

33/1000 Family history of postpartum psychosis

22/1000 Personal history bipolar disorder: 1/2 Sequelae: Future Postpartum Psychosis

Postpartum Depression Not as mild or

transient as the blues

Not as severely disorienting as psychosis

Range of severity Often undetected

Postpartum Depression: Risk Factors Lower SES/unemployment Past depression or anxiety disorder Past history of alcohol abuse Stressful life-events Poor marital relationship Inadequate social support Child-care related stressors African American ethnicity

Effects of Perinatal Depression:An Overview Depression negatively effects:

Mother’s ability to mother Mother—infant relationship Emotional and cognitive

development of the child

Postpartum Depression:Maternal Attitudes– Infants perceived to be more

bothersome

– Make harsh judgments of their infants

– Feelings of guilt, resentment, and ambivalence toward child

– Loss of affection toward child

Postpartum Depression:Maternal Behaviors

Gaze less at their infants Take longer to respond to infant’s utterances Show fewer positive facial expressions Lack awareness of their infants Increased risk for abusing children

Postpartum Depression:Maternal Interactions

Flat affect, low activity level, and lack of contingent responding

OR

Alternating disengagement and intrusiveness

Effects of Maternal Depression Infants- lowered Brazelton scores,

frequent looking away, fussiness

Toddlers- poorer cognitive development, insecure attachment

Children- cognitive development of low ses boys

Adolescents-higher cortisol levels

What Can Be Done?

ROUTINE SCREENING

REFERRAL TO TREATMENT

Why Screen for Perinatal Depression?

Screening is associated with increased detection

Georgiopoulos et al., 1999, 2001– EPDS screening resulted in increased

chart-based diagnosis of PPD from 3.7% to 10.7% after one year of universal screening – Rochester, MN

Barriers to Detection Women will present themselves

as well as they are ashamed and embarrassed to admit that they are not feeling happy

Media images contribute to this phenomena

Barriers to Detection Women will present themselves

as well as they are ashamed and embarrassed to admit that they are not feeling happy– Tom Cruise: Snap out of it mentality

Media images contribute to this phenomena

Barriers to Detection (cont) Lack of knowledge about range of

postpartum disorders

They don’t want to be identified with Andrea Yeats

May genuinely feel better when you see them (they got dressed, out of house, lots of attention, not isolated)

“I Was Depressed But Didn’t Know It.”

Commonalities in the Experience of Non-depressed and Depressed Pregnant and Postpartum Women

Changes in appetite Changes in weight Sleep disruption/insomnia Fatigue/low energy Changes in libido

What is Required for Effective Screening?What to do with a positive screen?

1. Implement or refer for diagnostic assessment

Arrange for treatment2. Antidepressant medication3. Psychotherapy (individual or group)

Arrange for follow-up

THANK YOU