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CHAPTER 3 MOOD DISORDERS

CHAPTER 3 MOOD DISORDERS. AIMS AND OBJECTIVES. Provide overview of unipolar and bipolar depression Describe historical approaches, diagnostic criteria, and epidemiology Discuss current biopsychosocial approaches to the aetiology and treatment of mood disorders. UNIPOLAR DEPRESSION.

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CHAPTER 3 MOOD DISORDERS

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  1. CHAPTER 3MOOD DISORDERS

  2. AIMS AND OBJECTIVES Provide overview of unipolar and bipolar depression Describe historical approaches, diagnostic criteria, and epidemiology Discuss current biopsychosocial approaches to the aetiology and treatment of mood disorders

  3. UNIPOLAR DEPRESSION History of Classification In Ancient Greece, term “melancholia” to describe fear and depression Kraeplin (1896) used the term manic depressive insanity, which encompassed all mood disorders Since 1950s, classification system has distinguished between bipolar and unipolar depression Two types of unipolar depression: major depressive disorder and dysthymia

  4. UNIPOLAR DEPRESSION DSM-IV-TR Diagnosis of Major Depressive Disorder (MDD) Characterized by the occurrence of > 1 Major Depressive Episodes (MDEs) Criteria for an MDE Depressed mood and/or loss of interest (anhedonia) for > 2 weeks At least 4 of these additional symptoms: Appetite disturbance Sleep disturbance Fatigue Restlessness or slowed movements Poor concentration Feelings of worthlessness or guilt Thoughts of death or suicide

  5. UNIPOLAR DEPRESSION DSM-IV-TR Diagnosis of Dysthymia Diagnosed when depression is not severe to meet for MDD, but is of longer duration (> 2 years) Dysthymia + MDD referred to as “double depression” Other subtypes of depression Melancholic depression Psychotic depression Postnatal depression Seasonal affective disorder

  6. UNIPOLAR DEPRESSION Epidemiology of depression Prevalence In Australia: 3.4% of men, 6.8% of women over 1-year period Lifetime prevalence ~ 17% Women 2x as likely to have depression – cause of gender difference not completely known Age of onset As early as 3 years old, median age of onset = 30 years old Course Up to 50% with depression recover within 6 months of treatment 10% experience a chronic course Most who have an MDE will have another episode within 5 years

  7. UNIPOLAR DEPRESSION Aetiology of unipolar depression Biological factors Genetic factors – family history  2-3x increased risk Neurotransmitters – serotonin, norepinephrine, dopamine Neuroendocrine – hyperactivity in HPA axis Neurophysiological – abnormalities in brain structures, including prefrontal cortex, hippocampus, anterior cingulate, and amygdala Environmental factors Stressful life events Interpersonal difficulties High level of “expressed emotion” in families of depressed patients

  8. UNIPOLAR DEPRESSION Aetiology of unipolar depression Psychological factors Cognitive theories Seligman’s Learned Helplessness Model – depression linked with expectancy of helplessness in face of adverse events Beck - childhood experiences lead to dysfunctional beliefs, which are triggered by relevant events Negative Cognitive Triad = Negative view of self, world, and future Behavioural theories Influence of adverse events and/or lack of positive reinforcement Poor coping skills to deal with stressors Protective factors may reduce risk (e.g., good interpersonal skills, optimism)

  9. UNIPOLAR DEPRESSION Treatment Medical approaches Antidepressant medication Repetitive transcranial magnetic stimulation / Vagus nerve stimulation Bright light therapy (seasonal affective disorder) Electroconvulsive therapy (severe depression) Psychological approaches Cognitive behaviour therapy Behavioural activation and problem-solving Cognitive restructuring for dysfunctional thoughts Interpersonal psychotherapy Focus on interpersonal problems related to the depression

  10. BIPOLAR DISORDER History Descriptions of mania date back to ancient Greece In 19th century, mania and melancholia began to be considered as a single entity Kraeplin distinguished between “manic depressive insanity” and “dementia praecox”, e.g., schizophrenia In 1949 Australian researcher John Cade discovered lithium, whichrevolutionized the treatment of bipolar disorder Bipolar Diagnoses: Bipolar I, Bipolar II, and cyclothymia All 3 of these conditions involve mania or hypomania

  11. BIPOLAR DISORDER DSM-IV-TR defines a manic episode: Elevated, expansive or irritable mood > 1 week, plus 3 of the following: Inflated self-esteem Grandiosity Sleep disturbance Pressured speech Flight of ideas Distractibility Heightened activity Excessive risk taking Must be out of character for the individual DSM-IV-TR defines a hypomanic episode: Same symptom profile as mania, except Symptoms not severe enough to interfere with functioning, necessitate hospitalisation, or involve hallucinations/delusions DSM-IV-TR also includes the controversial construct of a mixed episode, in which both symptoms of a manic and major depressive episode present for > 1 week

  12. BIPOLAR DISORDER Bipolar I > 1 manic or mixed episodes (MDE can be present but not necessary) Bipolar II >1 MDE plus >1 hypomanic episode Cyclothymia Lacks severity to meet for Bipolar I or II Hypomanic episodes plus depressive symptoms that don’t meet for an MDE Relationship between schizophrenia and bipolar Often a mixture between mania and psychotic features Bipolar can be initially misdiagnosed as schizophrenia

  13. BIPOLAR DISORDER Epidemiology Lifetime prevalence of Bipolar I and II = 3.9% Men and women equally likely to meet for Bipolar I Women more likely to meet for Bipolar II High rates of relapse (73% over 5 years) Often problems with medication compliance Problems associated with bipolar disorders High rates of anxiety disorders and substance abuse among bipolar patients Substantial social and economic costs High rate of suicide (15x rate in general population)

  14. BIPOLAR DISORDER Aetiology Biological Factors Strong genetic component 13x increased risk among 1st degree relatives 85% heritability in large twin study Neurotransmitters play a role Stressful Events Diathesis-Stress Model – interaction between underlying vulnerability and stressful life event Goal Dysregulation Model – excessive goal engagement Psychological factors Cognitive disturbances – cause or consequence? Temperament – perfectionism and high need for social approval

  15. BIPOLAR DISORDER Treatment Pharmacological Mood stabilisers lithium, chlorpromazine, valproate, zyprexor, lamictal Psychological Psychoeducation for patients and families Cognitive behaviour therapy Interpersonal and social rhythm therapy Family interventions Relapse prevention

  16. SUMMARY Unipolar and Bipolar Depression History Diagnostic criteria Epidemiology Aetiology Biological Psychological Environmental Treatment Biological Psychological

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