Week 5 Depression & Bipolar Flashcards
Definition: Mood
A pervasive and sustained emotional response that can color perception (apa, 2013)
What is the most leading cause of disability world wise measured by years life lived with a disability?
Depression - 9.4 Total years lived with disability
Mood Disorders: Epidemiology
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
Major Depressive Disorder
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
Major Depressive Episode
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
Specifiers (most recent episode)
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
Differential Diagnosis - Medical Conditions
Neuroligical Problems
Parkinson’s diseas
Dementing illness
Epilepsy
Stroke
Tumours
Differential Diagnosis - Pharmacological agents
Numerous illicit/presciption drugs
Differential Diagnosis - Psychiatric disorders
Bipolar disorder
Differential Diagnosis
Comorbidity:
* Depression frequently coexists with: - Eating disorders
- Personality disorders
- Alcohol and drug abuse
- Anxiety disorders
Depression Course
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
Depression: Prognosis
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
Biploar Disorder Types
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
Manic Episode of Bipolar: Diagnostic Criteria
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
Hypomanic Episode
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
Bipolar Disorder: Differential Diagnosis with Medical Disorders
- Epilepsy
- Huntington’s
chorea - Multiple sclerosis
- Traumatic brain
injury - HIV/AIDS
Bipolar Disorder: Differential Diagnosis with Drugs
- Amphetamines
- Cocaine
- Hallucinogens
- Opiates
Psychiatric Disorders of special consideration for manic
symptoms are:
Schizophrenia
Personality disorders: Borderline
Narcissistic
Histrionic
Bipolar Disorder: Course
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
Bipolar: Prognosis
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
Suicide Risk
~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
Theoretical Accounts of the Causes of
Depression & Bipolar disorders
Biological models
Life Events Perspective
Behavioural theories
Cognitive theories
Seligman’s Learned Helplessness
Beck’s Cognitive Model
Interpersonal theories
Biological Models
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
Neurochemical Abnormalities
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
Neurochemical Abnormalities - Limitations
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
Life Events Perspective - Depression
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?
Life Events Perspective - Bipolar Disorder
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.
Behavioural Theory
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
Cognitive Theories
ABC
Learned helplessness (Seligman, 1975)
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.
Beck’s (1979) Model
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
Interpersonal Theory
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
Depression - Pharmacotherapy
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
Depression: Meds vs Psych Tx
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
Bipolar Disorder: Pharmacotherapy
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%
(Pharmacotherapy +) CBT
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
