Mood Disorders:

Depression, Mania, & Bipolar

Disorder

What is Mood?

Mood is a a conscious state of mind

or predominant emotion

Websters Dictionary

What is a Mood Disorder?

Involves disabling disturbances in

emotions that are markedly different
from normal functioning

Can also include cognitive &

behavioral disturbances

Generally occurs in discrete episodes

Depression extreme sadness
Mania extreme elation and irritability

Types of Mood
Disorders

Main Distinction: unipolar or bipolar

Unipolar: only one end of the emotion spectrum

Major Depressive Episode

Manic Episode

Bipolar: cycling between both ends of the emotion

spectrum

Bipolar Disorder

Other Disorders
Dysthymia: mild, chronic form of depression
Cyclothymia: similar to bipolar, but a more mild
form of mania (hypomania)

Bipolar Disorders

Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder

Manic Episode: DSM

Criteria
A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting at least 1 week (or any duration if
hospitalization is necessary).
During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have
been present to a significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of
sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant
stimuli)
(6) increase in goal-directed activity or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high
potential for painful consequences

Manic Episode RuleOuts

do not meet criteria for a Mixed Episode

Mixed episode = both manic and depressed nearly everyday for

at least one week

marked impairment in occupational functioning or in usual

social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or others,
or there are psychotic features

not due to the direct physiological effects of a substance

(e.g., a drug of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism)

Note: Manic-like episodes that are clearly caused by

somatic antidepressant treatment (e.g., medication,
electroconvulsive therapy, light therapy) should not count
toward a diagnosis of Bipolar I Disorder

Bipolar I

1 or more manic episodes; may have

had past depressive episodes or not

Lifetime Prevalence: about 1%; equal in

men and women

Course and Prognosis: poorer prognosis

than MDD

45% have one more episode

only 50-60% achieve control over Sx with lithium
40% develop a chronic disorder

Bipolar II

recurrent major depressive episodes

with hypomanic episodes
Hypomania - All the criteria of a Manic
episode except criterion C (marked
impairment)
NOT full-blown manic episodes, if an
individual does experience a manic
episode, they are then diagnosed with
Bipolar I Disorder

matter of differential diagnosis

Bipolar Disorder
Bipolar I
Alternation of full
manic and
depressive
episodes
Average onset is 18
years
Tends to be chronic
High risk for suicide

Bipolar II
Alternation of
Major Depression
with hypomania
Average onset is
22 years
Tends to be chronic
10% progess to full
biploar I disorder

Cyclothymia
A.

B.

C.
D.
E.

For at least two years (one year for children and

adolescents) presence of numerous hypomanic
episodes and numerous periods with depressed
mood or loss of interest or pleasure that did not
meet criterion A (5 symptoms) of Major Depression
During a two-year period (1 year in children and
teens) of disturbance, never without hypomanic or
depressive symptoms for more than tow months at
a time
No evidence of MDD or Manic episode during the
first two years of disturbance
No psychotic disorder
No organic cause

Mania Etiology

better-suited for the biological model

not normally distributed in the population
Symptoms are very marked and severe

not necessarily precipitated by a positive life

event & can override negative events
further evidence in favor of diathesis

Familial Pattern seen

Twin and adoption studies

What Does Mania Look

Like?
Client 1: Mary

Depressive Disorders

Major Depressive Disorder (single,

recurrent)
[Major Depressive Disorder:
Postpartum onset]**
Dysthymic Disorder
Double Depression
Postpartum depression as a specifier

What Does Depression Look

Like?

Sadness
Suicidal Thoughts
Tiredness
Boredom
Unwilling to get out
Insomnia

Depressive
Episode/Disorder:
DSM Criteria
Five or more of the following during the same 2-week
period that represent a change from usual functioning
including either (1) depressed mood or (2) loss of
interest.

Sad, depressed mood, most of the day, nearly every

day for two weeks
Loss of interest and pleasure in usual activities
Difficulties sleeping
Shift in activity level
Changes in appetite and weight loss/gain
Loss of energy, fatigue
Negative self-concept, self-blame, guilt, worthlessness
Difficulty concentrating
Recurrent thoughts of death or suicide

Depression Diagnosis
Rule-Outs

The symptoms do not meet criteria for a Mixed Episode

The symptoms cause clinically significant distress or

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

The symptoms are not due to the direct physiological

effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g.,
hypothyroidism).

The symptoms are not better accounted for by

Bereavement, i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are
characterized by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation.

Major Depression
MDD, Single
episode
Absence of
mania or
hypomania

MDD, Recurrent
2 major
depression
episodes,
separated by at
least a 2 month
period with more
or less normal
functioning/mood

Dysthymic Disorder:
Symptoms
Depressed/irritable mood
B.
Presence of two of the following:

Appetite disturbance

Sleep disturbance

Low energy/fatigue

Poor concentration of difficulties making decision

Feelings of hopelessness
C. Present for two year period (one year in children and
adolescents)
D. No evidence of a Major Depressive Epidsode during the
first two years (one year for children)
E. No manic or hypomanic episode
F. No chronic psychotic disorder
G. Not related to organic factors
A.

Double Depression

Not a diagnosis
Meet diagnostic criteria for both
MDD and Dysthymic Disorder

Prevalence

Point prevalence is the percentage

of the population who have the
disorder at a particular time or over
a given period of time.

Lifetime prevalence is the

percentage of individuals who have
ever had a specific disorder at any
time.

Facts About
Depression

Major depression is the single most

common psychiatric disorder in the U.S.
The point prevalence rate over a 1-year
period is 8% for men and 13% for
women.
Lifetime prevalence rate is 12.7% for
men and 21.3% for women.
In addition, depression is the most
common factor leading to suicide.

What Does Depression

Look Like?
Client 1: Mary

Client 2: Barbara

Client 3: Evelyn

Video Reactions?

What symptoms of depression did

you notice in these clients?

Any evidence of suicidal thoughts?

Which patient might be more likely

to commit suicide? Why?

Etiology: Biological

Genetic Factors
Family, twin, and adoption studies suggest
that depression in hereditary
More severe the depression in an individual,
more likely that relative have depression as
well
MDD concordance: 40% MZ, 10% DZ
Mania concordance: 75% MZ, 25% DZ
Severity of disorder is due to strength of
genetic loading

Etiology: Biological
cont.

Adoption studies
More mood disorders occur in the
biological relatives of those with
mood disorders
both unipolar and bipolar disorders
severity linked to the strength of the
genetic loading

Etiology: Biological Cont

Neurochemical Factors
Neurotransmitters
Norepinephrine
Serotonin
Dopamine

Not clear what processes are dysfunctional

(production, reuptake, chemical breakdown,
etc.)

Neuroendocrine changes

Hypothyroidisim

Research on
Neurotransmitters

norepinephrine & serotonin

Implicated in mania and depression

effectiveness of antidepressants
most drugs in psychiatry discovered by
accident

Not as simple a relationship as

previously thought
E.g. TCA and MAOI drugs

Permissive hypothesis

Becks Cognitive Theory

of Depression

distortions of reality & depressogenic

cognitions result in depression

schema filters and organizes

experiences to store beliefs and
knowledge about ourselves

cognitive triad of negative schemas

negative view of the self, the world, and the
future

Cognitive Theory Cont

negative automatic thoughts

further bias that individuals view of himself,
the world, and the future
e.g., arbitrary inference, selective
abstraction, overgeneralization,
magnification, etc.

thoughts focused on experiences of loss and

failure

research supports the presence of distorted,

automatic cognitions
the causal relationship of these factors not
established

Helplessness/Hopelessne
ss Model

Seligmans learned helplessness

model started as a conditioning
model with dogs

those who were exposed to

uncontrollable aversive situations
would develop depression that was
rooted in feelings of helplessness

Attributional Model

Abramson - Attribution of lack of control over

stress leads to anxiety and depression

Cognitive distortions affect the interpretation

of causes of events in peoples lives.

biased attributional style (i.e., a cognitive

style regarding beliefs about the causes of
events) characterized by internal, stable, and
global attributions.

Seligman and Beck

Seligman
Attributions are:
Internal
Stable
Global
I am inadequate (internal) at
everything (global) and I
always will be (stable).

Beck
Negative interpretations about:
Themselves
Immediate world (their
place)
Future (their place)
I am not good at school (self). I
hate this campus (world).
Things are not going to go
well in college (future).

Dark glasses about why

things are bad

Dark glasses about what is

going on

Interpretation (theory)

Description

Attributional Model Cont

Internal - attribute negative events to

own failings
Stable - belief that causes of negative
events remain constant
Global - assume causes of negative
events have broad and general effects
research supports the hopelessness
model
but cannot establish causal relationship

Major Depression: Social

and Cultural Factors

Stressful life events

Social support (marital
relationship) (see chart)
Gender
Culture (see chart)

Marital Status and MDD

Percentage w/MDD

Ethnicity and Prevalence

of MDD
Percentage by Ethnicity

Gender Differences in
Depression

Dr. Susan Nolen-Hoeksema

Women diagnosed twice as often as
men
difference not evident in childhood
boys and girls are just as likely to
experience depression
Changes in preteen years

What factors may be involved in the

development of these differences?

Diathesis-Stress Model

Neither biological nor environmental

and personal factors alone can produce
depression
a biological vulnerability (or diathesis)
interacts with life stressors to produce
depression
For example, a neurotransmitter dysfunction
may interact with life stressors (e.g., death
of a loved one) to produce depression

Diathesis-Stress Example

Depressio
n

Low NE

Normal NE

No Life Event
Event

Life

Comorbidity with Anxiety

distinguishing depression from anxiety difficult

Watson & Clark: tripartite model

Negative affectivity (NA) - pervasive individual
differences in negative emotionality and self-concept

Common to anxiety & depression

Anhedonia - lack of experiencing pleasure

specific to depression

Anxious arousal - physiological symptoms of anxiety

specific to anxiety disorders

Psychological Treatments
for Depression

Psychodynamic Therapies

Cognitive-Behavioral Therapies
Beck Cognitive Therapy
Social Skills Training
Behavioral Activation

Interpersonal Therapy

Depression Collaborative Research Program

Treatment
Groups

Cognitive
Therapy

Interpersonal
Psychotherapy

Medication
Imiprimine

Placebo & Clinical

Management

Outcome Measures
Depressive Symptoms
Overall symptomotology and life functioning
Functioning in treatment specific domains

Procedures
T16 weeks of treatment
Extensive Assessment:

Results

Results:

Follow-up-18 months

Post-Treatment
Equivalent success in three
active treatments over
placebo
Medication was faster
IPT better than CBT for more
severely depressed patients
Particular treatments effected
change in expected domains

Equivalent success in three active treatments

Only 20 to 30% of recovered patients were still
well
Patients in IPT report more satisfaction with
treatment
IPT and CBT patients more likely to report that
treatment affected capacity to establish and
maintain relationships and to understand source
of their depression

Many Controversial Issues

Biological Therapies for

Depression

Drug Therapies
Tricyclics
Selective serotonin reuptake
inhibitors
Monoamine oxidase inhibitors

Electroconvulsive Therapy

Mood Disorders:
Prevalence
Disorders
Major Depression
Dysthymia
Bipolar I
Bipolar II

Prevalence
4.9%
3.2%
0.8%
0.5

MDD (Postpartum)

13%

Suicide

8th leading cause of death in the U.S.

Overwhelmingly white phenomena
Suicide rates also quite high in Native
American
Rate of suicide is increasing in
adolescents and elderly
Males are more likely to commit suicide
Females are more likely to attempt
suicide (except China)

5 Myths and Facts

About Suicide
Myth #1:
People who talk
about killing
themselves
rarely commit
suicide.

Fact:
Most people who
commit suicide
have given some
verbal clues or
warnings of their
intentions

5 Myths and Facts

About Suicide
Myth #2:
The suicidal
person wants to
die and feels
there is no
turning back.

Fact:
Suicidal people
are usually
ambivalent about
dying; they may
desperately want
to live but can not
see alternatives
to problems.

5 Myths and Facts

About Suicide
Myth # 3:
If you ask
someone about
their suicidal
intentions, you
will only
encourage them
to kill
themselves.

Fact:
The opposite is
true. Asking lowers
their anxiety and
helps deter
suicidal behavior.
Discussion of
suicidal feelings
allow for accurate
risk assessment.

5 Myths and Facts

About Suicide
Myth # 4:
All suicidal
people are
deeply
depressed.

Fact:
Although depression
is usually associated
with depression, not
all suicidal people
are obviously
depressed. Once
they make the
decision, they may
appear
happier/carefree.

5 Myths and Facts

About Suicide
Myths # 5:
Suicidal people
rarely seek
medical
attention.

Fact:
75% of suicidal
individuals will
visit a physician
within the month
before they kill
themselves.

Sociodemographic Risk
Factors

Male
> 60 years
Widowed or Divorced
White or Native American
Living alone (social isolation)
Unemployed (financial difficulties)
Recent adverse life events
Chronic Illness

Clinical Risk Factors

Previous Attempts
Clinical depression or schizophrenia
Substance Abuse
Feelings of hopelessness
Severe anxiety, particularly with depression
Severe loss of interest in usual activities
Impaired thought process
Impulsivity

Assessing Risk and

Planning Intervention
Risk
Level

Specif
Risk
Severit Interve
c
Factors
y
n.
Plan
Intent

Low

No

Few

None

Safety Plan

Mod.

Vague
Plan/low
lethal

Increased

None

Safety Plan

Severe

Specific
lethal plan

Increased

None

Safety Plan
Remove
Lethal Items

Extreme

Specific
lethal plan

Increased

Intent to die

Safety Plan
Remove
Lethal Items
Hospitalize

Commonalities of
Suicide
(Schneiderman, 1985)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

purpose is to seek a solution.

goal is the cessation of consciousness (not
death).
stimulus is intolerable psychological pain.
stressor is frustrated psychological needs.
emotion is hopelessness-helplessness.
cognitive state is ambivalence.
perceptual state is constriction.
action is egression.
interpersonal act is communication of intention.
consistency is with lifelong coping patterns.

Clinical Considerations
of Suicide Assessment
For those who are reluctant to assess
suicide:

Asking questions may feel intrusive

but not asking has dangerous
consequences
A calm and genuinely concerned
approach is effective

Suicide:Treatment

Problem-solving
Cognitive behavioral therapy
Coping skills
Stress reduction

Postpartum Depression

Burden

In the United States, depression is the leading

cause of non-obstetric hospitalizations among
women aged 18-44.

In the year 2000, 205,000 women aged 18-44

were discharged with a diagnosis of
depression.

Seven percent of all hospitalizations among

young women were for depression.

Perinatal Depression:
Prevalence
Pregnancy

Postpartum

Kumar & Robeson

1984

13.4%

14.9%

Watson & Elliott

1984

9.4%

12.0%

OHara et al., 1984

Cooper et al. 1988

9.0%
6.0%

12.0%
8.7%

OHara et al., 1990

Evans et al., 2001

7.7%
13.6%

10.4%
9.2%

Postpartum Blues

Most common, 5080%

Relatively brief
Few hours to several
days

Onset usually in first

week to 10 days PP
Typically remit
spontaneously
May represent the
initial stages of PPD/PPP

Typical Blues
Symptoms

Low Mood
Mood Lability
Insomnia

Anxiety
Crying
Irritability

Postpartum
Psychosis

Rare: 1/1000 postpartum

women

Hallucinations and/or
Delusions

Risk Factors:
History Bipolar Affective
Disorder/Psychosis
Family history of
psychosis
Having first child
Aggressive intervention
absolutely necessary

Postpartum
Psychosis

Usually Begins Within 90 Days Postpartum

Length is Quite Variable
Prevalence: 1/500 to 1/1000
Family history of bipolar disorder 33/1000
Family history of postpartum psychosis
22/1000
Personal history bipolar disorder: 1/2
Sequelae: Future Postpartum Psychosis

Postpartum
Depression

Not as mild or
transient as the
blues
Not as severely
disorienting as
psychosis
Range of severity
Often undetected

Postpartum Depression: Risk

Factors

Lower SES/unemployment
Past depression or anxiety disorder
Past history of alcohol abuse
Stressful life-events
Poor marital relationship
Inadequate social support
Child-care related stressors
African American ethnicity

Effects of Perinatal
Depression:
An Overview

Depression negatively effects:

Mothers ability to mother

Motherinfant relationship
Emotional and cognitive
development of the child

Postpartum Depression
Maternal Attitudes
Infants perceived to be more
bothersome
Make harsh judgments of their infants
Feelings of guilt, resentment, and
ambivalence toward child

Postpartum Depression:
Maternal Behaviors

Gaze less at their infants

Take longer to respond to infants utterances

Show fewer positive facial expressions

Lack awareness of their infants

Increased risk for abusing children

Postpartum Depression
Maternal Interactions
Flat affect, low activity level, and lack of
contingent responding
OR
Alternating disengagement and intrusiveness

Effects of Maternal
Depression

Infants- lowered Brazelton scores, frequent

looking away, fussiness

Toddlers- poorer cognitive development,

insecure attachment

Children- cognitive development of low ses

boys

Adolescents-higher cortisol levels

What Can Be Done?

ROUTINE SCREENING

REFERRAL TO TREATMENT

Why Screen for

Perinatal Depression?
Screening is associated with
increased detection

Georgiopoulos et al., 1999, 2001

EPDS screening resulted in increased
chart-based diagnosis of PPD from
3.7% to 10.7% after one year of
universal screening Rochester, MN

Barriers to Detection

Women will present themselves as

well as they are ashamed and
embarrassed to admit that they are
not feeling happy

Media images contribute to this

phenomena

Barriers to Detection

Women will present themselves as

well as they are ashamed and
embarrassed to admit that they are
not feeling happy
Tom Cruise: Snap out of it mentality

Media images contribute to this

phenomena

Barriers to Detection
(cont)

Lack of knowledge about range of

postpartum disorders

They dont want to be identified with

Andrea Yeats

May genuinely feel better when you

see them (they got dressed, out of
house, lots of attention, not isolated)

I Was Depressed But

Didnt
Know
It.
Commonalities in the Experience of

Non-depressed and Depressed

Pregnant and Postpartum Women
Changes in appetite
Changes in weight
Sleep disruption/insomnia
Fatigue/low energy
Changes in libido

What is Required for

Effective Screening?
What to do with a positive screen?
1. Implement or refer for diagnostic
assessment

Arrange for treatment

1. Antidepressant medication
2. Psychotherapy (individual or group)

Arrange for follow-up