psyc4080 6.0d depression, bipolar disorder 1 mood disorders

PSYC4080 6.0D PSYC4080 6.0D Depression, Bipolar DisorderDepression, Bipolar Disorder 11

Mood DisordersMood Disorders


Mood DisordersMood Disorders

Refer to a number of disorders where the patient Refer to a number of disorders where the patient displays an “extreme” mood statedisplays an “extreme” mood state• Positive: Excitement, elationPositive: Excitement, elation• Negative: Sadness, emptinessNegative: Sadness, emptiness

Complex etiology: Most patients are believed to Complex etiology: Most patients are believed to have genetic predispositionhave genetic predisposition

Not necessarily triggered by a stressful eventNot necessarily triggered by a stressful event Extremely common, considered a major world Extremely common, considered a major world

health issue (WHO, 2006)health issue (WHO, 2006) Among the most treatable mental health Among the most treatable mental health

disordersdisorders


Prevalence of Mood DisordersPrevalence of Mood Disorders

Many people who suffer clinical depression do not Many people who suffer clinical depression do not seek treatmentseek treatment• Cultural, gender differencesCultural, gender differences

CAMH (Toronto) rates range from 10-25% of the CAMH (Toronto) rates range from 10-25% of the population seeking treatmentpopulation seeking treatment

Bipolar disorder is equally common in males and Bipolar disorder is equally common in males and femalesfemales

Major depression twice common in femalesMajor depression twice common in females• Women also more likely to seek treatment.Women also more likely to seek treatment.


Depression: Case StudyDepression: Case Study

A very capable professional woman in her mid-30s A very capable professional woman in her mid-30s became depressed as a consequence of difficulties in became depressed as a consequence of difficulties in conceiving a child. The couple had delayed trying to conceiving a child. The couple had delayed trying to have children, and desperately desired to become have children, and desperately desired to become parents. The difficulty in conceiving, and consequent parents. The difficulty in conceiving, and consequent involvement in an IVF program, also led to significant involvement in an IVF program, also led to significant marital stress.marital stress.

The patient had started to cry frequently and had some The patient had started to cry frequently and had some suicidal thoughts (although she had no intent to act upon suicidal thoughts (although she had no intent to act upon them). She had little energy and was easily fatigued -- in them). She had little energy and was easily fatigued -- in contrast to her usual active and productive self. contrast to her usual active and productive self.


Depression: Case StudyDepression: Case Study

She developed insomnia, her concentration was She developed insomnia, her concentration was impaired, and she lost her appetite. At times she would impaired, and she lost her appetite. At times she would shop and spend more than usual in order to cheer shop and spend more than usual in order to cheer herself up.She was referred to a counsellor for both herself up.She was referred to a counsellor for both individual and marital therapy. individual and marital therapy.

The individual counseling focused upon the issues of her The individual counseling focused upon the issues of her grief over not being able to bear children, her guilt about grief over not being able to bear children, her guilt about not attempting to conceive earlier, and the tension within not attempting to conceive earlier, and the tension within the marriage. However, despite skilled therapy for an the marriage. However, despite skilled therapy for an adequate time, her symptoms persisted. adequate time, her symptoms persisted.


Major Depressive EpisodeMajor Depressive Episode

A.A. Five or more of the following symptoms that:Five or more of the following symptoms that: present during the same 2-week period present during the same 2-week period change from previous functioningchange from previous functioning at least one of the symptoms is either (1) at least one of the symptoms is either (1)

depressed mood or (2) loss of pleasure.depressed mood or (2) loss of pleasure.(1)(1) depressed mood most of the day, nearly depressed mood most of the day, nearly

every day, as indicated by either subjective every day, as indicated by either subjective report (e.g. feels sad or empty) or report (e.g. feels sad or empty) or observation made by others (e.g. appears observation made by others (e.g. appears tearful). tearful).

Children or adolescents – irritabilityChildren or adolescents – irritability



(2) markedly diminished interest or pleasure in (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, all, or almost all, activities most of the day, nearly every day (self-report or anecdote)nearly every day (self-report or anecdote)

(3) significant weight loss when not dieting or (3) significant weight loss when not dieting or weight gain, or decrease or increase in weight gain, or decrease or increase in appetite nearly every day appetite nearly every day

children – failure to meet weight milestoneschildren – failure to meet weight milestones



(4) insomnia or hypersomnia nearly every (4) insomnia or hypersomnia nearly every dayday

(5) psychomotor agitation or retardation (5) psychomotor agitation or retardation nearly every day (observable by others, nearly every day (observable by others, not only through self-report)not only through self-report)

(6) fatigue or loss of energy nearly every (6) fatigue or loss of energy nearly every dayday


Major Depressive EpisodeMajor Depressive Episode(7) Feelings of worthlessness or excessive or (7) Feelings of worthlessness or excessive or

inappropriate guilt (which may be delusional) nearly inappropriate guilt (which may be delusional) nearly every dayevery day

(8) Diminished ability to think or concentrate, or (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (self-report or indecisiveness, nearly every day (self-report or anecdote)anecdote)

(9) Recurrent thoughts of death, recurrent suicidal (9) Recurrent thoughts of death, recurrent suicidal ideation (without a specific plan), or a suicide attempt ideation (without a specific plan), or a suicide attempt or a specific plan for committing suicideor a specific plan for committing suicide

B. The symptoms do not meet criteria for a B. The symptoms do not meet criteria for a mixed mixed episodeepisode (I.e. (I.e. in one day, rapid alternation between mania in one day, rapid alternation between mania and depression)and depression)


Major Depressive EpisodeMajor Depressive EpisodeC. Symptoms cause clinically significant distress or C. Symptoms cause clinically significant distress or

impairment in social, occupational, or other important impairment in social, occupational, or other important areas of functioning.areas of functioning.

D. The symptoms are not due to the direct physiological D. The symptoms are not due to the direct physiological effects of a substance, or a general medical condition.effects of a substance, or a general medical condition.

E. The symptoms are not better accounted for by E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are symptoms persist for longer than 2 months or are characterized by marked functional impairment.characterized by marked functional impairment.


Depressive DisorderDepressive DisorderMajor Depressive DisorderMajor Depressive Disorder Presence of a single MDE that is chronic (2 months)Presence of a single MDE that is chronic (2 months) Recurring MDE episodesRecurring MDE episodes

DysthymiaDysthymia not meeting full criteria not meeting full criteria relatively intact functional capacity (need 2 months relatively intact functional capacity (need 2 months

duration)duration) Specifiers: Postpartum onset, With seasonal pattern Specifiers: Postpartum onset, With seasonal pattern

(Seasonal Affective Disorder)(Seasonal Affective Disorder) Some features may be unusual (agitation, delusions, Some features may be unusual (agitation, delusions,

catatonia)catatonia)


Bipolar DisorderBipolar Disorder Much lower prevalence: 1-2% Much lower prevalence: 1-2% Atypical prior to age 12Atypical prior to age 12 Initially may characterize as Initially may characterize as cyclothymiacyclothymia: :

alternations between elevated and depressed alternations between elevated and depressed mood, without extreme effects on daily mood, without extreme effects on daily functioning.functioning.• May or may not progress to bipolar disorderMay or may not progress to bipolar disorder• Characterized by clinical depression (MDE) with Characterized by clinical depression (MDE) with

alternating manic or alternating manic or hypomanichypomanic episodes (elevated episodes (elevated mood, either extreme behaviour or not, respectively)mood, either extreme behaviour or not, respectively)


Case StudyCase Study

““Kevin”, a 28 year-old accountant, recently Kevin”, a 28 year-old accountant, recently separated from his wife of 6 years and was separated from his wife of 6 years and was apparently devastated by the breakup. His friends apparently devastated by the breakup. His friends at work described him as “extremely moody” at work described him as “extremely moody” after his wife left him.after his wife left him.

According to other people present, at the According to other people present, at the company Christmas party a few weeks later, company Christmas party a few weeks later, Kevin was having a casual yet involved discussion Kevin was having a casual yet involved discussion with some of his colleagues regarding dating and with some of his colleagues regarding dating and sexual prowess. sexual prowess.


Case StudyCase Study

With little warning, Kevin began bragging about how he had With little warning, Kevin began bragging about how he had slept with hundreds of women, and about the size of his slept with hundreds of women, and about the size of his penis. He then began ridiculing the other males in the penis. He then began ridiculing the other males in the crowd at how small their penises must be for not having crowd at how small their penises must be for not having slept with as many women as him. slept with as many women as him.

After some minutes of this screaming and taunting After some minutes of this screaming and taunting behaviour, Kevin challenged the other males in the group to behaviour, Kevin challenged the other males in the group to pull their pants down to “see what they were made of”. He pull their pants down to “see what they were made of”. He then took off his own clothes, jumped onto a nearby table then took off his own clothes, jumped onto a nearby table and started masturbating, screaming unintelligibly.and started masturbating, screaming unintelligibly.

Kevin was restrained by security shortly thereafter. A brief Kevin was restrained by security shortly thereafter. A brief hospitalization and eventual psychiatric assessment hospitalization and eventual psychiatric assessment confirmed that Kevin had experienced a Manic Episode.confirmed that Kevin had experienced a Manic Episode.


DSM-IV: Manic EpisodeDSM-IV: Manic EpisodeA.A. A distinct period of abnormally and persistently elevated, A distinct period of abnormally and persistently elevated,

expansive or irritable mood, lasting at least 1 week (or any expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)duration if hospitalization is necessary)

B. During the period of mood disturbance, 3 or more of the B. During the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if mood is irritable) following symptoms have persisted (4 if mood is irritable) and have been present to a significant degree:and have been present to a significant degree:

1) 1) inflated self esteem or grandiosityinflated self esteem or grandiosity

2) decreased need for sleep (e.g. feels rested after only 3 2) decreased need for sleep (e.g. feels rested after only 3 hours of sleep)hours of sleep)

3) more talkative than usual or pressure to keep talking3) more talkative than usual or pressure to keep talking


DSM-IV: Manic EpisodeDSM-IV: Manic Episode

4) flight of ideas, or subjective experience that 4) flight of ideas, or subjective experience that thoughts are racingthoughts are racing

5) distractibility5) distractibility

6) increase in goal-directed activity (work, 6) increase in goal-directed activity (work, school, or sexually) or psychomotor agitationschool, or sexually) or psychomotor agitation

7) excessive involvement in pleasurable 7) excessive involvement in pleasurable activities that have a high potential for painful activities that have a high potential for painful consequences consequences

unrestrained buying sprees, sexual unrestrained buying sprees, sexual indiscretions, or foolish business investmentsindiscretions, or foolish business investments



C. The symptoms do not meet criteria for a Mixed C. The symptoms do not meet criteria for a Mixed Episode Episode

D. The mood disturbance is sufficiently severe to D. The mood disturbance is sufficiently severe to cause cause marked impairment in occupational marked impairment in occupational functioningfunctioning or in usual social activities or or in usual social activities or relationships with others, or to necessitate relationships with others, or to necessitate hospitalization to prevent harm to self or others, hospitalization to prevent harm to self or others, or there are psychotic features.or there are psychotic features.



E. The symptoms are not accounted for by use of a E. The symptoms are not accounted for by use of a substance or medical condition.substance or medical condition.

HypomaniaHypomania: If symptoms persist for only 4 days, : If symptoms persist for only 4 days, and episodes do not affect everyday functioning.and episodes do not affect everyday functioning.


DSM-IV: Bipolar DisorderDSM-IV: Bipolar DisorderBipolar I Disorder, Single Manic Episode Bipolar I Disorder, Single Manic Episode A. Presence of only one Manic Episode and no past A. Presence of only one Manic Episode and no past

MDEs (could have dysthymia)MDEs (could have dysthymia)B. The Manic Episode is not better accounted for by B. The Manic Episode is not better accounted for by

Schizoaffective disorder, and is not superimposed Schizoaffective disorder, and is not superimposed on other psychotic disorders.on other psychotic disorders.


DSM-IV: Bipolar DisorderDSM-IV: Bipolar DisorderBipolar I Disorder, Most Recent Episode HypomanicBipolar I Disorder, Most Recent Episode HypomanicA. Currently or most recently in a Hypomanic A. Currently or most recently in a Hypomanic

EpisodeEpisodeB. There has previously been at least one Manic B. There has previously been at least one Manic

Episode or Mixed Episode.Episode or Mixed Episode.C. The mood symptoms cause clinically significant C. The mood symptoms cause clinically significant

distress or impairment in social, occupational, or distress or impairment in social, occupational, or other important areas of functioning.other important areas of functioning.

D. The mood episodes are not better accounted for D. The mood episodes are not better accounted for by Schizoaffective disorder, and is not by Schizoaffective disorder, and is not superimposed on other psychotic disorders.superimposed on other psychotic disorders.


DSM-IV: Bipolar DisorderDSM-IV: Bipolar Disorder Other subtypes: Other subtypes:

• Bipolar I Disorder, Most Recent Episode ManicBipolar I Disorder, Most Recent Episode Manic• Bipolar I Disorder, Most Recent Episode MixedBipolar I Disorder, Most Recent Episode Mixed• Bipolar 1 Disorder, Most Recent Episode DepressedBipolar 1 Disorder, Most Recent Episode Depressed• Bipolar II Disorder – no Mania or Mixed episodesBipolar II Disorder – no Mania or Mixed episodes

In all above cases, Major Depression must be In all above cases, Major Depression must be present. present.


Etiology of Mood DisordersEtiology of Mood Disorders

Note that most studies are done on patients Note that most studies are done on patients with years of depression or bipolar disorderwith years of depression or bipolar disorder

Begs the question of which came first, the Begs the question of which came first, the brain abnormalities or the depression.brain abnormalities or the depression.

Assumption is mood disorders are biological Assumption is mood disorders are biological because they respond to treatment.because they respond to treatment.


Etiology of Mood DisordersEtiology of Mood Disorders

Ignores negative thought patterns that can maintain Ignores negative thought patterns that can maintain depressive symptomatology – people with mood depressive symptomatology – people with mood disorders have been shown to think differently about disorders have been shown to think differently about themselves, others, and the world (Segal, 2004)themselves, others, and the world (Segal, 2004)

Common nature of depression argues against Common nature of depression argues against biological causebiological cause

Is depression adaptive?Is depression adaptive?


Neuropathology: DepressionNeuropathology: Depression Monoamine hypothesisMonoamine hypothesis: depression is caused : depression is caused

by insufficient activity of monoamines (NE and 5-by insufficient activity of monoamines (NE and 5-HT)HT)

Depression does not respond to DA agonistsDepression does not respond to DA agonists Lowering of NE and 5-HT metabolism in Lowering of NE and 5-HT metabolism in

depressed patients has been shown in PET depressed patients has been shown in PET studies (Bremner et al., 1997; Smith et al., 1999).studies (Bremner et al., 1997; Smith et al., 1999).

Substance P (peptide) shown to increase DA Substance P (peptide) shown to increase DA levelslevels• ventral tegmental area and prefrontal cortex and ventral tegmental area and prefrontal cortex and

alleviate symptoms of depression (Kramer et al., 1998; alleviate symptoms of depression (Kramer et al., 1998; Lejeune et al., 2002).Lejeune et al., 2002).


Neuropathology: DepressionNeuropathology: Depression Overactivity of the beta-adrenoreceptorOveractivity of the beta-adrenoreceptor

• G protein-coupled receptor involved in the synthesis of G protein-coupled receptor involved in the synthesis of second messengers or ion channelssecond messengers or ion channels

• These receptors are These receptors are desensitizeddesensitized by 5HT and NE by 5HT and NE

The effects of NE and 5HT on this receptor is The effects of NE and 5HT on this receptor is likely related to the delayed mood altering likely related to the delayed mood altering response of anti-depressantsresponse of anti-depressants


NeuropathologyNeuropathology

Depression is associated with decreased volume Depression is associated with decreased volume of the prefrontal cortex, basal ganglia, amygdala of the prefrontal cortex, basal ganglia, amygdala and cerebellum (Soares and Mann, 1997; Drevets, and cerebellum (Soares and Mann, 1997; Drevets, 2001) 2001)

Bipolar disorder is associated with decreased Bipolar disorder is associated with decreased volume of the cerebellum and temporal lobes volume of the cerebellum and temporal lobes (Soares and Mann, 1997) and increased volume (Soares and Mann, 1997) and increased volume of the ventricles (Strakowski et al., 2002).of the ventricles (Strakowski et al., 2002).


NeuropathologyNeuropathology

Seasonal pattern for depression:Seasonal pattern for depression:• Winter – cravings for carbohydrates and weight gain; Winter – cravings for carbohydrates and weight gain;

oversleep (may be treated with phototherapy in early oversleep (may be treated with phototherapy in early morning 4:30 a.m. to 6 a.m. seem to be peak times)morning 4:30 a.m. to 6 a.m. seem to be peak times)

• Summer – sleep less, lose appetite, and lose weightSummer – sleep less, lose appetite, and lose weight


Other InformationOther Information

Suicide Rate in Canada (StatsCan, 1997)Suicide Rate in Canada (StatsCan, 1997) Males: 19.6/100000Males: 19.6/100000 Females: 5.1/100000Females: 5.1/100000 Number of suicides have quadrupled since 1960, Number of suicides have quadrupled since 1960,

but have remained stable over the last 20 years.but have remained stable over the last 20 years. Rates are fairly steady over the lifespan (15+ Rates are fairly steady over the lifespan (15+

years of age), but it is rising in young adolescents years of age), but it is rising in young adolescents and childrenand children

A leading cause of death during adolescenceA leading cause of death during adolescence

psyc4080 6.0d depression, bipolar disorder 1 mood disorders

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