Depression and Mood Disorders

Question 1

Describe the characteristics and main diagnostic criteria of depression and bipolar disorder.

Answer 1

Depression is the prominent emotion in mood disorders, but it can be often associated with its opposite namely mania. Depression belongs to mood disorders; involve a disabling disturbance in emotion.

Mania is an emotion characterised by boundless, frenzied energy and feelings of euphoria. Involves hyperactivity, talkativeness, distractability, and intense elation. individuals who have bipolar disorder frequently oscillate between deep depression and frenetic mania.

Depression involves emotional, motivational, behavioural, physical and cognitive symptoms;

• emotional - negative emotions described as sad, hopeless, miserable, dejected and discouraged, often close to tears, frequent crying episodes, rarely experience positive emotions, loss sense of humour, anxiety common
• motivational - loss of interest in normal daily activities or hobbies, lack of initiative/spontaneity, social withdrawal, appetite and sexual desire diminished
• behavioural - slowness of speech and behaviour, physically inactive, stay in bed for long periods, decreased energy, tiredness and fatigue, exhibit characteristic postures and movements
• physical - sleep disturbance such as insomnia, headaches, indigestion, constipation, dizzy spells, general pain
• cognitive - negative views of themselves, the world around them, and their own future, which generates pessimistic thinking where sufferers believe nothing can improve their own lot. this leads to lack of initiative, impaired ability to think, concentrate or make decisions.

two main types of clinical depression:

• major depression - characterised by relatively extended periods of clinical depression that cause significant distress to the individual and impairment in social or occupational functioning. at least 5 symptoms need to be met to be diagnosed)
• bipolar disorder - characterised by periods of mania that alternate with periods of depression, and this leads individuals to describe their lives as an ‘emotional roller-coaster’. experience extremes of these emotions in ways that cause emotional discomfort and distress.

Major Depression:
defined by the presence of five or more depressive symptoms during the same 2 week period most days or most of the day. can be caused by a normal reaction to a number of life events (bereavement, financial problems, natural disasters). must cause clinically significant distress/ impairment in social, occupational or other areas of functioning. The symptoms are not the direct effect of a substance or medical condition. requires clinical judgement based on the individuals history and cultural norms. Diagnosis of this disorder requires symptoms such as:
- sleeping too much/little
- psychomotor agitation/retardation
- loss of energy
- weight loss or change in appetite
- feelings of worthlessness or excessive guilt
- difficulty concentrating/thinking/making decisions
- death or suicidal ideation

Persistent Depressive Disorder (Dysthymic disorder):
a form of depression in which the sufferer has experienced more than 2yrs of depressed mood for more days than not. experience many behavioural and cognitive characteristics of major depression, but these are less severe (meeting only 2 or more symptoms):
- poor appetite/overeating
- insomnia/hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
Major Depressive Disorder may precede this disorder, and major depressive episodes may occur during PDD.

reasons for diagnosing depression as controversial:
1)DSM-5 requires the identification of 5 symptoms for a period of 2 weeks for a diagnosis of major depression. but studies suggested that individuals with 3 symptoms exhibit similar levels of distress and problems with day to day living as individuals with 5 symptoms.
2) depression is experienced by almost everyone at some time in their life. in order for GP’s to provide treatment for individuals, there is a tendency for them to over dianose mild or moderate depression.
This raises issues including possible stigmatization that the label might cause for the patient and viewing depression as a ‘disease’. This increases the risk of the ‘medicalisation’ of normal everyday negative emotions such as mild distress or unhappiness.
3) depression occurs in a variety of different disorders which results in major depressive disorder as a relatively ‘pure’ diagnosis where the cause of depression cannot be attributed to either another disorder or to specific biological, environmental factors or other life events.

3 diagnosable problems with depression as a core element:

• premenstrual dysphoric disorder
• seasonal affective disorder (SAD)
• chronic fatigue syndrome (CFS)

Is depression a category or does it like on a continuum?

• disorders are categorised on the basis of groups of symptoms
• implies a person either has a psychological disorder or not
• this fails to capture differences in severity of disorder
• therefore created dimensional approach; consider disorders along a continuum in which people vary in degree of severity

Depression is highly comorbid with anxiety with around 60% of people with depression also experiencing anxiety disorder, this has given rise to a diagnostic category called mixed anxiety/depressive disorder.
This has led to researchers suggesting anxiety and depression are not truly independent disorders but represent subcategories of a larger group of emotional disorders with symptoms that can often intermix. 2%-3% of population has PDD and 5% of population currently depressed (MDD). Depression is a major public health issue, but doesn’t get the recognition it deserves.

Lifetime prevalence of major depression is around 20% for men and 30% for women; (why gender differences?) social pressure and stigma, symptoms not recognised, symptoms not seen as part of depression, women more encouraged to seek diagnosis, men deal differently (e.g. suicide rates higher), men more likely to self-medicate (recreational drugs - smoking, drinking), multiple roles for women in society, and biological differences.

WHO estimating 350 million people worldwide of all ages suffering from depression. Overall, lifetime risk of 17% (MDD). However, there are large variations across the world due to the stigmatization of psychopathology, higher levels of somatisation, depression is not observable therefore there is subjectivity in the way that symptoms are measured and recorded, and finally lifetime prevalence will always be affected by recall problems with age. women are almost twice as vulnerable to periods of major depression as men.

depression leading risk factor for suicide, 11-15% of patients with a diagnosis of major depression eventually die by their own hands. Department of Health lists suicide as the leading cause of death in men under the age of 35yrs old.

Question 2

Compare and contrast at least two biological theories of etiology of depression and mood disorders

Answer 2

THE AETOLOGY OF MAJOR DEPRESSION
Biological Factors

Biological Theories - Genetic Factors:
evidence to suggest that depressive symptoms run in families (inherited) with first degree relatives of major depression more likely to develop depressive symptoms. Twin studies based on heritability is moderate and estimated to be between 30 and 40%, with adoption studies suggesting that this is a genuinely inherited affect than a familial effect.
However, after two decades of research, genetic factors are still largely unknown.

Biological Theories - Neurochemical factors:
Major depression reliably associated with abnormalities in the levels of 3 brain neurotransmitters - serotonin, norepinephrine and dopamine (Delgardo & Moreno, 2000). In the 1950’s, many medications for high blood pressure caused depression as they decreased brain serotonin levels (Ayd, 1956). Tricyclic drugs (such as imipramine) and monoamine oxidase (MAO) inhibitors (such as tranylcyypromine) increase levels of serotonin and norepinephrine in the brain. therefore is was argued that depression was caused by low levels of either norepinephrine or serotonin activity. However, some researchers suggest depression is associated more with an imbalance in neurotransmitters than with deficits in specific neurotransmitters, others suggest both low levels of serotonin and high levels of norepinephrine result in mania.

Biological Theories - Brain Abnormalities and Depression:
studies identified abnormalities various brain areas associated with depression (prefrontal cortex, anterior cingulate cortex, hippocampus, and the amygdala). David et al. (2002) explains this;
- depression associated with low levels of activation in the prefrontal cortex, area represents maintaining goals and the means to achieve
- decreased anterior cingulate cortex (ACC) activation in major depression, area represents effortful emotional regulation required in situations where behaviour is failing to achieve a desired outcome.
- depression associated with dysfunction in the hippocampus as the individual would dissociate affective responses from their relevant contexts.
- depression associated with structural and functional abnormalities in the amygdala, and especially with increased amygdala activation. this results in prioritising threatening information for processing and interpreting information negatively

Biological Theories - Neuroendocrine factors:
evidence suggests from recent developments in brain scanning technology that identifies abnormalities in specific areas of the human brain that are associated with depression. hippocampal abnormalities is linked to high levels of cortisol (a hormone that is released in times of stress) which may influence depressive symptoms by enlargement of the adrenal glands and in turn lowering the frequency of serotonin transmitters in the brain.

Question 3

Compare and contrast at least two psychological theories of etiology of depression and mood disorders

Answer 3

THE AETOLOGY OF MAJOR DEPRESSION
Psychological Factors

Psychodynamic explanations:

Freud and Abraham view argues that depression is a response to loss, and in particular, a response to the loss of a loved one such as a parent (or separation or withdrawal).
The first stage of response to this loss is introjection, where the individual regresses to the oral stage of development. This allows them to integrate the identity of the person they have lost with their own and direct all feelings for the loved one onto themselves (including anger and guilt). They begin to experience self-hatred that developed rapidly into low self-esteem which adds to feelings of depression and hopelessness. Depression returns the person to a period (oral stage of development) in their life when they were dependent on others (their parents). this evolves into depending on their relationships with others in order to utilize the support that this will offer.

problems with this account:

• not everyone who experiences depression has lost a loved one, which led Freud to propose the concept of symoblic loss in which other kind of losses within one’s life (e.g. losing a job) are viewed as equivalent to losing a loved one.
• much of the empirical evidence does not differentiate between other theoretical approaches of depression
• many of the concepts are difficult to test

Behavioural explanations:
claim that depression results from a lack of appropriate reinforcement for positive and constructive behaviours, and this is especially the case following a ‘loss’ such as bereavement or losing a job

Interpersonal explanations:
claim that depressed individuals alienate family and friends (limited social support network; low social skills) because of their perpetual negative thinking, and this alienation in turn exacerbates the symptoms of depression. They seek reassurance from others, but this reassurance in temporary (problem with theory).

Negative Cognitions and Self-schema:
Becks cognitive theory of depression argues that depression is maintained by a ‘negative schema’ that leads depressed individuals to hold negative views about themselves, their future and the world (the ‘negative triad’).
The negative triad (negative views about themselves, their future and the world) leads to the cognitive biases in information processing (all events are interpreted negatively), which results in failures and losses (the individual fails to take initiatives, and opportunities are lost) which in turn leads to depression.
A negative schema is a set of beliefs that tends individuals towards viewing the world and themselves in a negative way.
we can associate depression and Beck’s cognitive theory of depression with pessimistic thinking caused by negative self-schemas. Pessimistic thinking is a form of dysfunctional thinking where sufferers believe nothing can improve their lot. However, evidence suggests that what depressed individuals may actually lack is the positive interpretation bias (to interpret ambiguous events negatively) possessed by non-depressed individuals.

Cognitive biases in depression:

• arbitrary inference refers to a conclusion drawn in the absence of sufficient evidence (e.g. i am about to meet my criteria today, but I might not feel so good about them)
• selective abstraction refers to a conclusion drawn on one of many elements in a situation
• overgeneralisation refers to an overall sweeping conclusion drawn on a basis of a trivial event
• magnification and minimisation involves giving proportionally greater weight to a perceived failure, weakness or threat, or lesser weight to a perceived success, strength or opportunity.

Learned Helplessness and attribution:
argues that people become depressed following unavoidable negative life events (sudden death of loved one, redundancy) because these events give rise to a cognitive set that makes individuals learn to become ‘helpless’, lethargic and depressed (Seligman, 1975).
Seligman (1974) used the learned helplessness theory and found that dogs that were given prior unavoidable shocks were subsequently unable to learn the avoidance response and simply lay down in the apparatus and ‘quietly whined’.
This appears to have a formalistic similarity to human depression, however there are various reasons for why that is not a full or comprehensive account of depression. Walker (2000) argued that a pattern of repeated partner abuse leads battered women to believe that they are powerless to change their situation. as a result, such women come to exhibit all the symptoms of depression and display ‘passivity’ found in battered syndrome women.
The difficulties and inconsistencies of the learned helplessness theory led to the creation of attribution theories. The theories argue that people who are likely to become depressed attribute negative life events to internal, stable and global factors. Their attributional styles result in pessimistic thinking.

Hopelessness Theory:
Hopelessness is a cluster of depressive symptoms that are characterised by an expectation that positive outcomes will not occur, negative outcomes will occur, and the individual has no responses available that will change this state of affairs.
As attributional and helplessness theory, this theory follows the idea of a diathesis-stress approach.
Explains a disorder, or its trajectory, as a result of an interaction between a predisposition vulnerability (diathesis) and a stress caused by life experiences (stress).
this theory predicts that other factors such as low self-esteem and suicidal tendencies, may also be involved as vulnerability factors.

Rumination Theory:
Rumination is the tendency to repetitively dwell on the experience of depression or its possible causes. Either in a repetitive or ‘brooding’ fashion or in an analytical way that attempts to seek explanations for the experience. Depressive rumination can increase the risk of depression or increase the risk of relapse (predictive).

Rumination is driven by meta-cognitive beliefs that rumination is a necessary process to undertake in order to resolve depression, and these beliefs contribute to the repetitive nature of depressive rumination. Other studies showed rumination relating to overgeneral autobiographical memory, which is a common characteristic of depressed individuals.

Question 4

Bipolar Disorder

Answer 4

is a mood characterised by alternating periods of depression and mania. often the wings between these two states are rapid, taking the individual from an extreme ‘high’ to ‘low’ quickly.

Characteristics of BD:

• expression of a constant
• sometimes unconnected
• stream of thoughts and ideas
• attention span may be limited
• person shifts rapidly from topic to topic
• they will be loud and often interrupt
• start conversations with strangers spontaneously
• indulge in inappropriate or imprudent sexual interactions

two main types of bipolar disorder; bipolar disorder I and bipolar disorder II. In bipolar disorder II, major depressive episodes alternate with periods of hypomania. Cyclothymic is also a mild form of bipolar disorder which ranges from mild depression to mania. Hypomania are defined as mild manic episodes. bipolar disorder is suggested to have a lifetime prevalence rate of around 1% (0.4-1.6%).

Criteria for a manic episode:
unusual and continual elevated, unreserved or irritable mood and usual and continual increase in energy levels lasting at least a week
presence of at least 3 of the following -
- infalted self-esteem or grandiosity
- less need for sleep
- increased talkativeness
- racing thoughts
- easily distractible
- increase in goal-directed activity or unintentional and purposeless motions
- unnecessary participation in activities with a high potential for painful consequences

Criteria for bipolar disorder I:

• presence or history of at least one manic episode (s)
• the manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes
• symptoms are not better accounted for by schizoaffective disorder or other disorders

Criteria for bipolar disorder II:

• presence or history of at least one depressive episode (s)
• presence or history of at least one hypomanic episode (s)
• no history of manic episodes (s)
• symptoms are not better accounted for by schizoaffective disorder or other disorders

Criteria for hypomania:
unusual and continual elevated, unreserved or irritable mood and usual and continual increase in energy levels lasting at least a week
presence of at least 3 of the following -
- infalted self-esteem or grandiosity
- less need for sleep
- increased talkativeness
- racing thoughts
- easily distractible
- increase in goal-directed activity or unintentional and purposeless motions
- unnecessary participation in activities with a high potential for painful consequences
-a noted change in functionality which is not usually seen in the individual and changes in functionality and mood are noticeable by others
- the episode is not due to the use of medication, drug abuse or other treatment

Criteria for cyclothymic disorder:

• for at least 2yrs there have been many periods with hypomanic symptoms that do not meet the criteria for a hypomanic episode and many periods with depressive symptoms that do not meet the criteria for a major depressive episode. these symptoms have not been absent for more than 2mnths at a time.
• no major depressive episode, manic episode or hypomanic episode has been present in the first 2yrs of the disorder
• the episode is not due to the use of medication, drug abuse or other treatment.

Question 5

Bipolar Disorder

The aetology of Bipolar Disorder
Biological Theories

Answer 5

Genetic Factors:
there is good evidence for a genetic component to BD. generally, 10% to 25% of first degree relatives of BD sufferers alsor report symptoms of mood disorder, as do 5-10% of first degree relatives of major depression sufferers.

Neurochemical Factors:
BD has also been shown to be reliably associated with abnormalities in levels of brain neurotransmitters (dopamine and norepinephrine irregularities). the mania found in BD is found to be associated with high levels of norepinephrine. common forms of treatment for BD is a combination of the antipsychotic drug olanzapine and the antidepressant SSRI drug flueoxetine (Prozac). can take affect within a 7-9 week period compared with placebo controls, but it is unclear how the beneficial effects of this drug combination might act through their effects on specific brain neurotransmitters.

Question 6

Triggers for depression and mania in BD

Answer 6

two significant triggers for mania in BD include goal attainment and sleep disruption.
others are:
- seasonality
- reactions to antidepressant medication
- stressful life events
- exposure to high emotional expression in family members or caregivers

Question 7

The Treatment of Depression and Mood Disorders

Answer 7

BIOLOGICAL THERAPIES OF MOOD DISORDERS

drug treatments have been developed that attempt to address the imbalance in neurotransmitters such as serotonin, dopamine and norepinephrine.

Three main types of medication for depression are trycyclic drugs, monoamine oxidase (MAO) inhibitors, and selective serotonin reuptake inhibitors (SSRI’s). These drugs work by blocking re-uptake of noradrenaline and/or 5HT (Serotonin) from the synaptic cleft. Antidepressants are an effective treatment for depression, but many patients discontinue treatments because of side effects, or dislike of taking medicines long-term.

Lithium carbonate is the main drug prescribed for bipolar disorder.

Symptoms of bipolar disorder have also been treated successfully with a combination of antidepressant and antipsychotic drugs (e.g. loanzapine and fluoxetine).

We know that antidepressants - Anderson, 2013:
We know that antidepressants: get into the brain; need certain pharmacology properties; have acute and chronic neurochemical effects; influence neuronal circuitry underpinning mood; alter emotional processing; have biological actions comprising only a modest part of the overall therapeutic effect.

We don’t know: the specific pharmacological, neuronal, neuropsychological actions necessary or sufficient for efficacy; how these interact with non-specific and psychological factors; how to effectively sequence treatment based on pharmacology; how to predict who will benefit from which, or any, drug. Effective prescribing remains an art in which how treatment is carried out is as important as what drug is used.

Electroconvulsive therapy (ECT) is sometimes used with individuals suffering severe depression who have not responded well to other forms of treatment. However, it mechanism of action is unknown. It involves the induction of brain seizures by the application of electrical current to the skull. Side effects such as autobiographical memory loss are commonly reported.

PSYCHOLOGICAL THERAPIES FOR MOOD DISORDERS

Psychodynamic therapy uses a range of techniques (e.g. free association, dream analysis) to help the individual to explore the long-term sources of their depression.

Social skills training assumes that depression results from the depressed individuals inability to communicate and socialise appropriately, and addresses this deficit using social skills training programmes. it explores improving social interactions so as to lift depression; an effective treatment for depression.

Behavioural activation therapies attempt to increase the individuals access to pleasant events and rewards and decrease their experience of aversive events. Involves tracking their own goals along with clinicians who used a token economy to reinforce success in moving through the hierarchy of activities.

Cognitive therapy for depression attempts to help the depressed individual identify negative beliefs and thoughts, challenge these beliefs as irrational, and replace them with positive rational beliefs. Becks approach is an effective therapy for depression. Outcome studies suggest that cognitive therapy is at least as effective as drug therapy;
•Cognitive retraining or cognitive restructuring – 3 steps 1. identify negative beliefs/thoughts patterns,
2. challenge them as dysfunctional;
3. replace them with more adaptive beliefs – e.g. recognizing overgeneralizing
•Identifying negative automatic thoughts
•Reattribution training: interpreting difficulties in a more hopeful and constructive way

Interpersonal Therapy (IPT) had its roots in psychodynamic theory and focuses on changing the way the individuals interpersonal relationships with others; IPT is an effective therapy for depression. IPT looks at 4 problem areas:
1. Grief
•e.g. abnormal grief reactions. IPT facilitates mourning and helps form new relationships.
2. Fights
•Communication, negotiation and assertiveness skills are taught.
3. Role transitions
•Retirement, divorce, leaving home – focus on establishing new social supports.
4. Social deficits
•Role playing and enhanced communication skills are used to overcome recurrent weaknesses in social relationships.

Extract from Mastering Depression: The Patient’s Guide to Therapy:
“The IPT therapist will not:
•Interpret your dreams
•Have treatment go on indefinitely
•Delve into your early childhood
•Encourage you to free associate
•Make you feel very dependent on the treatment or the therapist”
Mindfulness-based cognitive therapy (MBCT) has been developed to prevent relapse in recovered depressed individuals by making them aware of negative thinking patterns that may be triggered by subsequent bouts of depression.

computerised CBT is also an effective treatment for milder forms of depression.

both behavioural and cognitive therapies appear to have promise as long-term effective treatments for depression, and these therapies help the sufferer by enabling them to identify and challenge ingrained negative views of themselves and the world.

Are psychological interventions effective treatments for depression?
•Several studies appeared in the 1980’s which compared CBT versus antidepressant medication, and the results were very positive, CBT appeared to be at least as effective as drugs in the treatment of out-patients who were suffering from a major depressive episode.
•However, biologically minded psychiatrists were not overly impressed by this data and raised the following criticisms in relation to these early trials:

Four main criticisms of the ‘early’ CBT trials:

1. Studies were carried out by committed cognitive therapists, therefore had a vested interest in the results?
2. Low (inadequate?) antidepressant dose used in some studies - unfair comparison with CBT?
3. In some studies, patients were recruited on the basis of elevated Beck Depression Inventory (BDI) scores - sadness, not clinical depression was being “treated”?4.Main outcome measure in most studies was the BDI, a self-report questionnaire which is heavily “cognitively biased” - the subjects were not recovering from depressive illness, rather they were being trained to complete the questionnaire in a manner more pleasing to their therapist?

Question 8

Suicide

Answer 8

over half of those successfully commit suicide are significantly depressed before the fatal attempt.

suicidal ideation is reported by 13.5% of people during their lifetime.

women are more likely to attempt suicide than men, but the rate for successful suicide is 4 times higher in men than women.

risk factors for suicide include an existing psychiatric diagnosis, low self-esteem, poor physical health and physical disability, and experiencing a significant negative life event.

there is an inherited component to suicide which may be as high as 48%

the main forms of intervening to prevent suicide include 24hr helplines and telephone support lines (e.g. the Samaritans), and school-based educational programmes warning about the early signs of suicidal tendencies

both medications for mood disorders and CBT can be helpful in reducing suicide risk in vulnerable people.

Question 9

Enhanced Care

Answer 9

Chronic disease management - Enhanced Care advocated
•Case manager (e.g. practice nurse)
•Adherence to evidence based treatment guidelines
•Outcomes should be monitored – how is outcome measured at GP?
•Treatment plans changed when patients do not improve
•Case manager and GP should refer to mental health specialist when necessary

Enhanced care - recommendations
•Primary care of major depression can be enhanced by case management for each patient
•Fluid working relationship between case manager, GP and mental health specialist
•Effective treatment can be provided in primary care, minority needing specialist care can be identified and referred more reliably

Managing Depression as a Chronic Disease - Rost et al. BMJ (2002),
•Enhanced care versus treatment as usual
•Enhanced care achieved by training practice staff
•Aim to give patients presenting with depression 2 years of high quality treatment
•First objective to increase the proportion of patients who received pharmacotherapy or psychotherapy
•Nurse care managers phoned patients and assessed depressive symptoms, encouraged treatment adherence or to raise continuing problems with doctor at next visit
.•Doctors received monthly summaries of patient symptoms and current treatments from nurse managers

Conclusion:

• Enhanced care led to significantly improved outcome for depressed patients
• At 24 months 74% of enhanced care patients were in remission versus 41% in treatment as usual
• QoL as measured by SF-36 Emotional role functioning and Physical role functioning were significantly higher at 24 months in the enhanced care group
• Small but continued investment in the depressed population significantly reduced disability