Week 5 Depression & Bipolar

Question 1

Definition: Mood

Answer 1

A pervasive and sustained emotional response that can color perception (apa, 2013)

Question 2

What is the most leading cause of disability world wise measured by years life lived with a disability?

Answer 2

Depression - 9.4 Total years lived with disability

Question 3

Mood Disorders: Epidemiology

Answer 3

 Lifetime risk for major depressive disorder prevalence ~ 16%
 More prevalent in females
 Lifetime risk for bipolar I and II disorders combined ~ 4%
 Equal prevalence for males and females
 No race, urban/rural or SES distinctions for mood disorders

Question 4

Major Depressive Disorder

Answer 4

Presence of at least one Major Depressive Episode
Not better explained by Not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified
and unspecified schizophrenia spectrum and other psychotic
disorder
Never been manic or hypomanic episode

Question 5

Major Depressive Episode

Answer 5

A.Five (or more) present during same two week period and represents change from previous
functioning; at least one of the symptoms is either (I) depressed mood or (II) loss of interest or pleasure
1. Depressed mood
2. Diminished interest or pleasure
3. Significant weight loss or gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue
7. Feelings of worthlessness or excessive/inappropriate guilt
8. Diminished ability to concentrate/indecisiveness
9. Recurrent thoughts of death/suicidality
B.Cause clinically significant distress or impairment in functioning C.Not attributed to substance or another medical condition

Question 6

Specifiers (most recent episode)

Answer 6

Severity/psychotic/remission
 With anxious distress
 With mixed features
 With melancholic features
 With atypical features
 With mood-congruent psychotic features
 With mood-incongruent psychotic features
 With catatonia  With postpartum onset  With seasonal pattern

Question 7

Differential Diagnosis - Medical Conditions

Answer 7

Neuroligical Problems
Parkinson’s diseas
Dementing illness
Epilepsy
Stroke
Tumours

Question 8

Differential Diagnosis - Pharmacological agents

Answer 8

Numerous illicit/presciption drugs

Question 9

Differential Diagnosis - Psychiatric disorders

Answer 9

Bipolar disorder

Question 10

Differential Diagnosis

Answer 10

Comorbidity:
* Depression frequently coexists with: - Eating disorders
- Personality disorders
- Alcohol and drug abuse
- Anxiety disorders

Question 11

Depression Course

Answer 11

50% have 1st episode < 40 yrs
 Untreated episode lasts 6-13 months
 Most treated episodes last ~ 3 months  Withdrawal of antidepressants < 3 months may lead to relapse
 5-10% with an initial diagnosis of MDD have a manic episode 6-
10 years after first episode of depression

Question 12

Depression: Prognosis

Answer 12

MDD fundamentally a cyclic disorder
Risk of recurrence increased by: History of more than one previous depressive episode
Co-existing: - Persistent depressive disorder
- Alcohol and/or drug abuse - Anxiety symptoms

Question 13

Biploar Disorder Types

Answer 13

BIPOLAR I DISORDER
At least one Manic episode
Most recent episode:  Hypomanic  Manic  Depressed
 Unspecified

BIPOLAR II DISORDER
 One or more Major Depressive
episodes accompanied by at
least one Hypomanic episode
 Never had a manic episode

Question 14

Manic Episode of Bipolar: Diagnostic Criteria

Answer 14

Distinct period of abnormally and persistently elevated, expansive or irritable mood & goaldirected activity, energy – at least one week B. Three or more of the following:
1. Inflated self-esteem/grandiosity
2. Decreased need for sleep
3. Increased speech, talkativeness, or pressure of speech
4. Flight of ideas or racing thoughts
5. Distractibility – reported or observed
6. Increased goal-directed activities or psychomotor agitation
7. Excessive involvement in pleasurable activities with high potential for painful consequences C. Marked impairment in functioning or needs hospitalization or psychotic features D. Not due to effects of substances or another medical condition

Question 15

Hypomanic Episode

Answer 15

Meets most of the criteria for Manic episode, except not as severe:  Lasts at least four consecutive days
 Associated with uncharacteristic change in functioning
 Observable to others
 Not severe enough to cause marked impairment in social or
occupational functioning, or to necessitate hospitalisation, and no
psychotic features

Question 16

Bipolar Disorder: Differential Diagnosis with Medical Disorders

Answer 16

• Epilepsy
• Huntington’s
  chorea
• Multiple sclerosis
• Traumatic brain
  injury
• HIV/AIDS

Question 17

Bipolar Disorder: Differential Diagnosis with Drugs

Answer 17

• Amphetamines
• Cocaine
• Hallucinogens
• Opiates

Question 18

Psychiatric Disorders of special consideration for manic
symptoms are:

Answer 18

 Schizophrenia
 Personality disorders:  Borderline
 Narcissistic
 Histrionic

Question 19

Bipolar Disorder: Course

Answer 19

Bipolar disorder often starts with depression: 75% in females, 67% in males
Age of onset 18 to 22 years
Recurring illness
Most experience depression and mania
10-20% experience only manic episodes
With chronicity, amount of time between episodes often
decreases
Emotional rollercoaster

Question 20

Bipolar: Prognosis

Answer 20

Worse prognosis than depressive disorders
Those with pure manic symptoms do better than those with depressed or mixed
symptoms
Good prognosis indicators: Short duration of manic episodes
Older age of onset Few suicidal thoughts
Few co-existing psychiatric/medical problems
Social Morbidity
Occupational impairment (20 - 50%) Social/interpersonal (20 - 50%) Higher divorce rate among bipolar than unipolar depressives
Alcohol abuse More severe the disorder the more frequent the alcoholism
Suicidal behaviour higher in bipolar than unipolar depressions  Risk mitigated through controlled bipolar symptoms

Question 21

Suicide Risk

Answer 21

~50% of all individuals completing suicide have a depressive or
bipolar disorder
Holma et al (2014) found:  9.5% with MDD attempted suicide
 19.9% with BD attempted suicide

Question 22

Theoretical Accounts of the Causes of
Depression & Bipolar disorders

Answer 22

Biological models
Life Events Perspective
Behavioural theories
Cognitive theories
Seligman’s Learned Helplessness
Beck’s Cognitive Model
Interpersonal theories

Question 23

Biological Models

Answer 23

Genetics - The Pedigree Method

Biological models
Life Events Perspective
Behavioural theories
Cognitive theories
Seligman’s Learned Helplessness
Beck’s Cognitive Model
Interpersonal theories

• Heritability estimate for Bipolar Disorder = 80%; Depression = 52%
• Polygenic influences

Question 24

Neurochemical Abnormalities

Answer 24

Catecholamine Hypothesis
 Excess (especially noradrenaline) causes mania and too little causes depression
Supportive evidence:  Functional levels of noradrenaline in the synapse increased with tricyclic medications
 Noradrenaline levels in manic patients have been found to be higher then those of depressed
or control subjects
 Bipolar patients given a blood pressure drug known to reduce noradrenaline supply in the
brain show a reduction in manic symptoms
 Lithium reduces noradrenaline activity at key neural sites

Indolamine Hypothesis
Deficiency in serotonin also related to depression
Some antidepressants produce increases in serotonin

Question 25

Neurochemical Abnormalities - Limitations

Answer 25

 Complex inter-relationships between neurotransmitters and other
biological systems which preclude a simple deficit model  A simple biochemical deficit/excess model cannot account for a
heterogeneous disorder like depression which involves a
dysregulation of many functions

Question 26

Life Events Perspective - Depression

Answer 26

Depression
 Prospective studies highlight events involving loss
 EE linked to relapse  Hostility, criticism, emotional over-involvement
BUT
 Environmental precipitants not always identified
 Mediators critical to understanding effects of life events?

Question 27

Life Events Perspective - Bipolar Disorder

Answer 27

 Life events often precede bipolar episodes
 Schedule disrupting events
 Goal attainment events
 Attributional styles and dysfunctional attitudes interact with
intervening life events
 Family discord predicts poor short-term outcomes.

Question 28

Behavioural Theory

Answer 28

Lewinsohn (1975):  Depression occurs as a result of a reduction in responsecontingent positive reinforcement

Three ways in which insufficient reinforcement may occur:-
1. Environment produces a loss of reinforcement
2. Lack of requisite skills
3. Unable to enjoy or receive satisfaction from reinforcement

Question 29

Cognitive Theories

Answer 29

ABC

Question 30

Learned helplessness (Seligman, 1975)

Answer 30

Learned Helplessness (Seligman, 1975)
Attributions vary along several dimensions:  Personal → universal  Pervasive/Global → specific
 Permanent/Stable → unstable The more personal, stable and global the attributions about negative
events, the more likely depressive symptoms are to occur.  “I’m stupid as I failed the test because I am totally hopeless with any sort of
test situation and I will never pass this course.

Question 31

Beck’s (1979) Model

Answer 31

Negative Triad
(Pessimistic view of self, world, & future)
↓ ↑
Negative Schemata or Beliefs Triggered by Negative Life Events
(e.g., the assumption that I have to be perfect)
↓ ↑
Cognitive Biases
(e.g., arbitrary inference)
↓
DEPRESSION

Question 32

Interpersonal Theory

Answer 32

Role of social support in health
People with depression:
* Social networks are sparse and less supportive
* Social skills deficits
Specific domains of interpersonal difficulty:
* Problem-solving skills
* Marital communication
Bipolar Disorder:
* Low social support associated with longer episodes

Question 33

Depression - Pharmacotherapy

Answer 33

Categories of antidepressants
* Selective serotonin reuptake inhibitors (SSRIs)
* Tricyclics (TCAs)
* Monoamine oxidase inhibitors (MAO-Is)
Side effects
* Dry mouth, urinary retention, sexual dysfunction, constipation, hypertension…
* May provoke episode of mania in bipolar pts
SSRIs - most frequently used form of antidepressant

Question 34

Depression: Meds vs Psych Tx

Answer 34

National Institute of Mental Health (USA) Study of Treatment of
Depression:  IPT, CBT & Tricyclic Antidepressants equally effective
 Relapse: % of patients who remained well at 18 month followup:  30% from CBT
 26% from IPT
 19% from Tricyclic group
 20% from placebo group

Question 35

Bipolar Disorder: Pharmacotherapy

Answer 35

Lithium Standard drug for treatment of manic episodes & cyclothymia
Alleviates manic episodes for some
Effective also when experiencing a depressive episode
Maintained use between episodes – less likely to relapse
~ 60% of bipolar and cyclothymic patients respond well to lithium Non-compliance - about 57%

Question 36

(Pharmacotherapy +) CBT

Answer 36

Typical CBT programs include: Psychoeducation
Thought records and mood diaries
Activity scheduling
Sleep hygiene
CBT & pharmacotherapy compared with treatment as usual (Swartz &
Swanson, 2014) Reduces relapse rates
 Improves functioning, symptoms and depression severity
Cost effective due to reduced service use