Gross Deviations in Mood Depression: “The Low”

– The “Common Cold” of Mental Illness– Major Depressive Episode is Most

Common Mania: “The High”

– Abnormally Exaggerated Elation, Joy, or Euphoria

Gross Deviations in Mood Depression: “The Low”

– The “Common Cold” of Mental Illness– Major Depressive Episode is Most

Common Mania: “The High”

– Abnormally Exaggerated Elation, Joy, or Euphoria

ManiaMania

DepressionDepression

Unipolar Mood Disorder– Either Depression or Mania

Bipolar Mood Disorder– Alternates Between Depression and Mania

Important to Determine the Course– Temporal Patterning of the Episodes

Unipolar Mood Disorder– Either Depression or Mania

Bipolar Mood Disorder– Alternates Between Depression and Mania

Important to Determine the Course– Temporal Patterning of the Episodes

Depressive Disorders– Major Depression– PDD, formerly Dysthymic Disorder– “Double Depression” - - dysthymia

punctuated by period of major depression

Bipolar I and Bipolar II Disorders– Cyclothymic Disorder

Depressive Disorders– Major Depression– PDD, formerly Dysthymic Disorder– “Double Depression” - - dysthymia

punctuated by period of major depression

Bipolar I and Bipolar II Disorders– Cyclothymic Disorder

Extremely Depressed Mood– Lasting at Least 2 Weeks

Cognitive Symptoms Anhedonia Vegetative Symptoms Single or Recurrent Episode

– No Manic or Hypomanic Episodes

Extremely Depressed Mood– Lasting at Least 2 Weeks

Cognitive Symptoms Anhedonia Vegetative Symptoms Single or Recurrent Episode

– No Manic or Hypomanic Episodes

Clinical Description Clinical Description

Similar to Major Depression BUT With a Different Course – Symptoms are Milder

– Symptoms can Last 20-30+ Years

Persistently Depressed Mood for 2+ Years– Cannot be Symptom Free > 2 Months

Similar to Major Depression BUT With a Different Course – Symptoms are Milder

– Symptoms can Last 20-30+ Years

Persistently Depressed Mood for 2+ Years– Cannot be Symptom Free > 2 Months

Clinical Description Clinical Description

Facts and Statistics Facts and Statistics Mean Age of Onset Early 20s Onset Prior to Age 20

– Greater Chronicity

– Poor Prognosis

Major Depressive Episodes are Common

Mean Age of Onset Early 20s Onset Prior to Age 20

– Greater Chronicity

– Poor Prognosis

Major Depressive Episodes are Common

Suffer From Both – Major Depression Episodes

– PDD - Dysthymic Disorder

Dysthymia Usually Begins First Associated With Severe Pathology A Problematic Future Course

Suffer From Both – Major Depression Episodes

– PDD - Dysthymic Disorder

Dysthymia Usually Begins First Associated With Severe Pathology A Problematic Future Course

Clinical Description Clinical Description

DysthymiaDysthymia

MajorDepression

MajorDepression

DysthymiaDysthymia

Clinical Description Clinical Description

Major Features Major Features Experience Both

– Manic Episodes

– Major Depressive Episodes

Roller Coaster of Mood

Experience Both– Manic Episodes

– Major Depressive Episodes

Roller Coaster of Mood

What are Manic Episodes?What are Manic Episodes?

Mania and Hypomania Mania and Hypomania

Elevated Mood Elevated Mood

Grandiosity Grandiosity

Increased Activity Increased Activity

Varied Impairment Varied Impairment

MajorDepression

MajorDepression

ManiaMania

Clinical Description Clinical Description

Major Depressive Episodes

Alternate With Hypomanic Episodes

Major Depressive Episodes

Alternate With Hypomanic Episodes

Clinical Description Clinical Description

Milder Depressive Episodes

Alternate With Hypomanic Episodes

Milder Depressive Episodes

Alternate With Hypomanic Episodes

Clinical Description Clinical Description

Clinical Description Clinical Description

DysthmiaDysthmia

HypomaniaHypomania

General Facts and Statistics General Facts and Statistics Bipolar I

– Onset Around 18 Years

Bipolar II – Onset Around 22 Years

16% Commit Suicide Cyclothymia

– Typically Chronic

Bipolar I– Onset Around 18 Years

Bipolar II – Onset Around 22 Years

16% Commit Suicide Cyclothymia

– Typically Chronic

Descriptions of Recent Episode and Pattern Varies Descriptions of Recent Episode and Pattern Varies

1. Atypical– Pertains to Depressive Episodes and Dysthymia,

not Manic Episodes– Typically Overeat and Oversleep

1. Atypical– Pertains to Depressive Episodes and Dysthymia,

not Manic Episodes– Typically Overeat and Oversleep

Recent Episode and Pattern Recent Episode and Pattern

2. Melancholic– Pertains to Major Depressive Episode

Only– More Severe Symptoms– Strong Biological Component

2. Melancholic– Pertains to Major Depressive Episode

Only– More Severe Symptoms– Strong Biological Component

Atypical (overeat, oversleep, wght gain – keep interested, can experience pleasure)

Atypical (overeat, oversleep, wght gain – keep interested, can experience pleasure)

Recent Episode and Pattern Recent Episode and Pattern

3. Mixed Features– With some mania symptoms

3. Mixed Features– With some mania symptoms

Atypical Atypical Melancholic Melancholic

Recent Episode and Pattern Recent Episode and Pattern

4. Catatonic– Can be part of Major Depression and

Mania– Very Serious Condition– Catalepsy (“Muscle Rigidity”)

4. Catatonic– Can be part of Major Depression and

Mania– Very Serious Condition– Catalepsy (“Muscle Rigidity”)

Atypical Atypical Melancholic Melancholic Mixed Mixed

Recent Episode and Pattern Recent Episode and Pattern

Catatonic Catatonic

Atypical Atypical Melancholic Melancholic Mixed Mixed

5. Psychotic– Hallucinations and Delusions– Very Rare but Serious Condition– Poor Treatment Response

5. Psychotic– Hallucinations and Delusions– Very Rare but Serious Condition– Poor Treatment Response

Recent Episode and Pattern Recent Episode and Pattern

Catatonic Catatonic

Atypical Atypical Melancholic Melancholic Mixed Mixed

6. Peripartum– Major Depression and Mania– Prior to…Four Weeks Following

Birth…and up to a year: high % – Mood Episodes of a Psychotic Nature

Relatively Rare

6. Peripartum– Major Depression and Mania– Prior to…Four Weeks Following

Birth…and up to a year: high % – Mood Episodes of a Psychotic Nature

Relatively Rare

Psychotic Psychotic

Recent Episode and Pattern Recent Episode and Pattern

Catatonic Catatonic

Atypical Atypical Melancholic Melancholic Mixed Mixed

Peripartum Anxious Distress

Peripartum Anxious Distress

Psychotic Psychotic

Course and Pattern Course and Pattern Rapid-Cycling Rapid-Cycling Seasonal Pattern

– Bipolar and Recurrent Major Depression– Episodes During Certain Seasons

Seasonal Pattern– Bipolar and Recurrent Major Depression– Episodes During Certain Seasons

• Premenstrual Dysphoric Disorder (PMDD)– 2- 5% of women meet criteria

• Disruptive Mood Dysregulation Disorder

– Children: increased diagnosis for bipolar, up 40% between 1995 and 2005

• Bipolar (NOS)

Other Depressive Disorders - new to DSM-5

About 16% Lifetime Global Prevalence MDD Past Year:

Bipolar-.8% Maj Depression-6%

Females > Males– Major Depression and Dysthymia

Females = Males– Bipolar Disorders

About 16% Lifetime Global Prevalence MDD Past Year:

Bipolar-.8% Maj Depression-6%

Females > Males– Major Depression and Dysthymia

Females = Males– Bipolar Disorders

Biological Dimensions Biological Dimensions Family Studies Twin Studies

– As Severity Increases, so Does the Genetic Connection

No Single Genetic Link

Family Studies Twin Studies

– As Severity Increases, so Does the Genetic Connection

No Single Genetic Link

Neurotransmitters Neurotransmitters The Serotonin Connection The Serotonin Connection

Endocrine Function Endocrine Function Elevated Cortisol Dexamethasone Suppression Test:

cortisol suppressed in non-depressed people, not in severely depressed….but….

Elevated Cortisol Dexamethasone Suppression Test:

cortisol suppressed in non-depressed people, not in severely depressed….but….

Sleep and Circadian Rhythms Sleep and Circadian Rhythms Sleep Disturbances are Common More intense and earlier start to REM Sleep among the Depressed Diminished Deep Sleep Disruption of Circadian Rhythms

Sleep Disturbances are Common More intense and earlier start to REM Sleep among the Depressed Diminished Deep Sleep Disruption of Circadian Rhythms

Stressful Life Events; Loss Learned Helplessness Attributional Style

Stressful Life Events; Loss Learned Helplessness Attributional Style

Internal Stable Global

Internal Stable Global

Negative Cognitive Biases Beck’s Cognitive Triad

Negative Cognitive Biases Beck’s Cognitive Triad

Negative Schema About

Self,

World,

& Future

Negative Schema About

Self,

World,

& Future

In the United States: In the United States: About 30,000 Kill Themselves Annually More Die from Suicide Each Year Than Homicide

(about 20,000) More Common Among Whites, Native Americans Increasing in Adolescents (3rd leading cause of

death) & Elderly (globally, the elderly have highest suicide rate, esp. males)

Males > Females in Killing Themselves Females > Males in Attempts

About 30,000 Kill Themselves Annually More Die from Suicide Each Year Than Homicide

(about 20,000) More Common Among Whites, Native Americans Increasing in Adolescents (3rd leading cause of

death) & Elderly (globally, the elderly have highest suicide rate, esp. males)

Males > Females in Killing Themselves Females > Males in Attempts

Approximately 500,000 people each year require ER

treatment as a result of attempted suicide Suicidal behavior typically occurs in the presence of

mental illness or substance use disorders Firearms account for 59% of all suicide deaths

Website of Extreme and Urgent Interest suicidology.org

Approximately 500,000 people each year require ER treatment as a result of attempted suicide

Suicidal behavior typically occurs in the presence of mental illness or substance use disorders

Firearms account for 59% of all suicide deaths

Website of Extreme and Urgent Interest suicidology.org

Medications Medications Tricyclic Antidepressants

Imipramine (Tofranil)

Amitriptyline (Elavil) Block Neurotransmitter Reuptake Side Effects

Tricyclic Antidepressants

Imipramine (Tofranil)

Amitriptyline (Elavil) Block Neurotransmitter Reuptake Side Effects

Medications Medications MAO Inhibitors Block Enzyme MonoAmine Oxidase The Result?

More Neurotransmitter is Available Side Effects and Complications

MAO Inhibitors Block Enzyme MonoAmine Oxidase The Result?

More Neurotransmitter is Available Side Effects and Complications

Medications Medications SSRIs Block Reuptake of Serotonin- Prozac SSNRIs

SSRIs Block Reuptake of Serotonin- Prozac SSNRIs

Medications - Bipolar Medications - Bipolar Lithium, Depakote, Lamictal…Effective

for Manic Episodes Lithium Must be Carefully Regulated

Lithium, Depakote, Lamictal…Effective for Manic Episodes

Lithium Must be Carefully Regulated

Other Medical Treatments Other Medical Treatments Electroconvulsive Therapy (ECT) TMS

Electroconvulsive Therapy (ECT) TMS

Psychological Interventions Psychological Interventions

Combined Treatments? Combined Treatments?