Depression, Bipolar

Question 1

Depression

Answer 1

• Depressed mood, anhedonia (loss of interest), changes in appetite/sleep/activity, psychomotor retardation/agitation, sad thoughts etc.
• 4 categories: mood, behavioral, cognitive, and physical
• Symptoms should last 2 weeks or more.
• Comorbidity is common

Question 2

Subtypes of depression (8)

Answer 2

1. Anxious distress: prominent anxiety symptoms
2. Mixed: manic/hypomanic
3. Melancholic: inability to experience pleasure, depressed moor, guilt, anorexia/weight loss, psychomotor retardation/agitation.
4. Psychotic: mood-congruent/incongruent delusions/hallucinations
5. Catatonic: not relating to environment, mimicking, mutism etc.
6. Atypical: positive mood to some event, weight gain, hypersomnia, sensitivity to interpersonal rejection.
7. Seasonal: atleast 2 years, one season a year.
8. Peripartum: during or in the 4 weeks following delivery.

Question 3

Prevalence and course

Answer 3

• 2.5% (children), 8.3% (adolescents) and 24% (adults)
• 18-29 and 85+
• Women twice as likely as men
• Relapse is very high - 75%

Question 4

Biological theories of depression: genetics

Answer 4

• First-degree relatives are 2 to 3 times more likely to have depression.
• Twins show high concordance rates for MZ.
• Begins early in life - strong genetic base compared to if it starts later in life.
• Serotonin transporter gene (5HTT): abnormalities lead to dysfunction in the regulation of serotonin which affects stability of mood.

Question 5

Biological theories of depression: neurotransmitters

Answer 5

• Monoamines: norepinephrine, serotonin and dopamine. They are synthesized in tryptophan and tyrosine and abnormalities in synthesis process = depression.
• Large concentrations in limbic system: regulates sleep, appetite and emotional processes.

Question 6

Biological theories of depression: brain abnormalities (4)

Answer 6

1. Prefrontal cortex
   - Attention, working memory, planning and problem solving
   - Reduced metabolic activity and reduction in the volume of gray matter on left side.
   - Longer EEG waves on left side.
   - Antidepressants increases activity here.
2. Anterior cingulate
   - Role in stress, emotional expression and social behavior.
   - Different levels of activity than controls
3. Hippocampus
   - Memory and fear related learning
   - Smaller volume and lower metabolic activity
   - Elevated levels of cortisol here leads to high stress levels.
4. Amygdala
   - Directs attention to stimuli that is emotionally salient and significant.
   - Enlargement and increased activity.
   - Overactivity may bias people toward aversive and emotionally arousing information = rumination.

Question 7

Psychological theories of depression: behavioral

Answer 7

1. Self-perpetuating chain: life stress = depression because it reduces positive reinforces = withdrawal = further reduction of reinforcers.
2. Learned helplessness: uncontrollable -ve events = depression = cannot control outcome in environment (helpless) = no motivation = depression.

Question 8

Psychological theories of depression: cognitive

Answer 8

1. Negative cognitive triad: -ve about themselves + the world + the future = errors in thinking.
2. Reformulated learned helplessness theory: explanation of -ve event through internal, stable and global causes blame themselves and expect -ve events again = long-term helplessness and loss of self-esteem.
3. Ruminative response styles: process of thinking rather than content of thinking.
4. Memory bias: remember -ve events.
5. Over-general memory: vague and general memories of painful events = coping mechanism

Question 9

Psychological theories of depression: interpersonal

Answer 9

• Chronic conflict in relationships with family, friends etc.
• Rejection sensitivity: seek for reassurance and acceptance = others become weary and frustrated = MDD become insecure = seek more = others withdraw themselves = more depression.

Question 10

Psychological theories of depression: sociocultural

Answer 10

1. Cohort effects: historical changes
   - 20% before and now 40%
2. Gender differences:
   - Men more likely to cope with alcohol and women to ruminate and seek treatment.
   - Social norms
3. Ethnicity/race differences:
   - Hispanic culture = high prevalence = poverty, unemployment and discrimination.
   - African Americans = lower rates of depression = but more anxiety = disadvantage status.

Question 11

Bipolar disorder

Answer 11

• Mania: positive/grandiose self-esteem, racing thoughts/impulses, fast speech, agitated/irritable, bipolar 1.
• Depression: hypomania (symptoms of mania but not severe enough, do not involve hallucinations/delusions) + depressive symptoms.

Question 12

Prevalence and course for bipolar

Answer 12

• Less common than depression
• 0.6% for bipolar 1 and 0.4% for bipolar 2.
• Men and women equal, non consistent difference across groups or cultures.
• Variability can occur due to genetic factors.
• Comorbidity with other disorders.
• Substance/alcohol abuse common.
• Most do not receive treatment.

Question 13

Biological theories of bipolar: genetics

Answer 13

• First-degree relative have 5-10 times higher rates to develop.
• Identical twins are 45-75 times more likely to develop.

Question 14

Biological theories of bipolar: brain abnormalities

Answer 14

1. Amygdala and prefrontal cortex (processing of emotions + cognitive control and plannning.
2. Hippocampus has no link
3. Striatum is abnormally activated when rewarding stimuli is present. Leads to inflexible responses to reward.
   - Mani phase = highly sensitive to reward
   - Depressive phase = insensitive to reward
4. Abnormalities in white matter in the prefrontal cortex = difficulties in communication and control. Leads to disorganized emotions and extreme behaviors.

Question 15

Biological theories of bipolar: neurotransmitters

Answer 15

• Dis-regulation in the dopamine system = bipolar
• High levels of dopamine = high reward seeking
• Low levels of dopamine = insensitivity to reward

Question 16

Psychosocial theories of bipolar:

Answer 16

• Relapse if sensitive to rewards and punishment
• Stressful events/unsupportive family triggered new episodes.
• Changes in bodily rhythms or usual routines triggers episodes.

Question 17

Biological treatment for mood disorders: drugs for depression (5)

Answer 17

1. SSRIs: fewer side effects, safer, positive effects,
2. Selective serotonin-norepinephrine re-uptake inhibitors (SNRIs): broader array of side effects.
3. Bupropion (norepinephrine + dopamine): useful for psychomotor retardation, anhedonia, hypersomnia, cognitive slowing, inattention and craving.
4. Tricyclic antidepressants: less frequent, lots side effects (blood pressure drop, cardia arrhythmia), overdose easy, suicidal thoughts.
5. Monoamine oxidase inhibitor (MAOIs): breakdown monoamine, increases levels of NTs, effective but dangerous side effects (liver damage, high blood pressure)

Question 18

Biological treatment for mood disorders: Mood stabilizers for bipolar

Answer 18

1. Lithium
   - Improves functioning of intracellular processes
   - Reduces relapse of mania/depression.
   - Effective dose vs overdose is small
   - Side effects range from abdominal pain to kidney dysfunction.
   - 55% develop resistance within 3 years and 33% remain symptom free.
2. Anticonvulsant and atypical antipsychotic drugs
   - Treats seizures and mood regulation.
   - Side effects are fatigue, vertigo, dizziness, liver disease.
   - Causes birth defects, does not prevent suicide.
   - Restores balance between neurotransmitter system in the amygdala.
   - Antipsychotic drugs: reduce levels of dopamine (mania)
   - Side effects: weight gain and metabolic changes.

Question 19

Biological treatment for mood disorders: electroconvulsive therapy

Answer 19

• Induced brain seizure by passing electrical current.
• 70-130 volts for 1 second.
• Convulsion of 1 minute.
• 6-12 sessions.
• ECT results in metabolic activity in regions including frontal and anterior cingulate.
• Side effects: memory loss, difficulty learning new information (administered on the right side).
• Relapse is 85%.

Question 20

Biological treatment for mood disorders: brain stimulation (3)

Answer 20

1. Repetitive transcranial magnetic stimulation (rTMS)
   - repeated high intensity magnetic pulses focused on particular brain structures.
   - left prefrontal = low metabolic activity
   - few side effects = minor headaches.
2. Vagus nerve stimulation (VNS)
   - Device surgically implanted in the left chest wall.
   - Increases activity in the hypothalamus and amygdala (antidepressant effect)
3. Deep brain stimulation (DBS)
   - electrodes implanted connected to a pulse generator under skin and stimulates those areas.
   - Relieves intractable depression.

Question 21

Biological treatment for mood disorders: light therapy

Answer 21

• Helps with seasonal depression.
• 57% showed remission of symptoms by 79% with combo of CBT.
• Reduces symptoms by resetting circadian rhythms (hormones and neurotransmitters)
• Reduces melatonin which increases norepinephrine and serotonin.

Question 22

Psychological treatment for mood disorders: behavioral

Answer 22

• Focuses on increasing positive reinforcers and decreasse aversive experiences in the patients’ life by changing their patterns of interaction with environment.
• Short term, 12 weeks.
• Functional analysis, solutions.

Question 23

Psychological treatment for mood disorders: CBT

Answer 23

1. Aims to change the negative, hopeless patterns of thinking.
2. Solve concrete problems in their lives and develop skills.
   - Brief, 6-12 weeks.

Question 24

Psychological treatment for mood disorders: Interpersonal

Answer 24

• Looks at 4 types of problems within depressed individuals
  1. Losing someone
  2. Interpersonal role disputes
  3. Role transitions
  4. Deficits in interpersonal skills.
• Help them face such problems and begins with investing in new relationships

Question 25

Psychological treatment for mood disorders: interpersonal and social rhythm

Answer 25

- Specifically for bipolar - Helps maintain routines of eating, sleeping and activity as well as stability within their personal relationships. - Work together to develop a plan to stabilize one’s activities - Usually used in conjunction with drugs.

Question 26

Psychological treatment for mood disorders: family focused therapy

Answer 26

- Reduce interpesonal stress within context of the family - Education about the disorder and training in communication and problem-solving skills. - Low relapse rate over time.

Question 27

Biological theories of depression: Neuroendocrine factors

Answer 27

- HPA-axis = elevated levels of cortisol and CRH, chronic hyperactivity, does not return to normal functioning after stressor. - Early traumatic stress leads to neuroendocrine abnormalities. - Changes in ovarian hormones affects serotonin and norepinephrine NTs which affects mood.