Depression and Bipolar Disorders

8/6/2019 Depression and Bipolar Disorders

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Dept of Psychiatry

University of Zambia


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I. IntroductionII. Clinical features of mood disorders

A. Description of mood disorders

B. Diagnostic criteriaC. Epidemiology and natural historyIII. Effects of treatments on mood disorders

A. Long-term outcomes of mood disorders andthe 5 R's of antidepressant treatment

B.

Search for subtypes of depression that predictresponse to antidepressantsC. The good news and the bad news about

antidepressant treatmentsD. Longitudinal treatment of bipolar disorderE. Mood disorders across the life cycle: When do

antidepressants start working?


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` IV. Biological basis of depression

A. Monoamine hypothesis

B. Monoaminergic neurons1. Noradrenergic neurons

2. Dopaminergic neurons

3. Serotonergic neurons

C. Classical antidepressants and themonoamine hypothesis

D. Neurotransmitter receptor hypothesis

V. Summary


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` Depression and mania are often seen as opposite ends ofan affective or mood spectrum.

` Classically, mania and depression are "poles" apart, thusgenerating the terms unipolar depression, in which patients just experience the down or depressed pole and bipolardisorder, in which patients at different times experienceeither the up (manic) pole or the down (depressed) pole. Inpractice, however, depression and mania may occursimultaneously, which is called a "mixed" mood state.Mania may also occur in lesser degrees, known as"hypomania," or may switch so fast between mania anddepression that it is called "rapid cycling.


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` Depression is an emotion that is universally

experienced by virtually everyone at some time in

life.

` Distinguishing the "normal" emotion of depressionfrom an illness requiring medical treatment

` Depression is not a disease but a deficiency of

character, which can be overcome with effort.


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` 71% Due to emotional weakness

` 65% Caused by bad parenting

` 45% Victim's fault; can will it away

` 43% Incurable

` 35% Consequence of sinful behaviour

` 10% Has a biological basis; involves the

brain


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` Stigma and misinformation can also extend into

medical practice, where many depressed patients

present with medically unexplained symptoms.

` "Somatization"When a person uses physical symptoms to

express emotional distress.

` Major reason for misdiagnosis of mental illness


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` Many depressed patients with somatic complaints

are considered to have no real or treatable

illness and thus are not treated for a psychiatricdisorder once medical illnesses are evaluated and

ruled out.

` In reality, however, most patients with diffuse

unexplained somatic symptoms in primary caresettings either have a treatable psychiatric illness

(e.g., anxiety or depressive disorder) or are

responding to stressful life events.

` Such patients do not generally have a genuinesomatization disorder in which "their symptoms

are really all in their mind."


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` Accepted, standardized diagnostic criteria are

used to separate "normal" depression caused by

disappointment or "having a bad day" from the

disorders of mood.

` Such criteria also are used to distinguish feeling

good from feeling "better then good (hypomania)

and expansive and irritable that amount to mania


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Clusters of symptoms in depression:

` Vegetative

` Cognitive

` Impulse control` Behavioral

` Physical (somatic)


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` vegetative features: sleep, appetite, weight, andsex drive;

`

cognitive features:attention span, frustration tolerance, memory,negative distortions;

` Impulse control:

suicide and homicide;` behavioral features: motivation, pleasure,

interests, fatigability; and

` physical {or somatic) features: headaches,stomach aches, and muscle tension


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` What is the incidence of major depressive disorder

versus bipolar disorder?

` How many people have the condition at the

present time, and how many in their lifetimes?` Are individuals with mood disorders being

identified and treated, and if so, how?

` Also: What is the outcome of their treatment?

` What is the natural history of their mood disorderwithout treatment and how is this affected by

treatment?


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` The incidence of depression is about 5% of thepopulation, whereas the incidence of bipolar disorderis about 1%.

` Unfortunately, only about one-third of individuals with

depression are in treatment, not only because ofunder recognition by health care providers but alsobecause individuals often conceive of their depressionas a type of moral deficiency, which is shameful andshould be hidden. Individuals often feel as if they

could get better if they just "pulled themselves up bythe bootstraps"


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` The reality is that depression is an illness, not a

choice, and is just as socially debilitating as

coronary artery disease and more debilitating than

diabetes mellitus or arthritis.

` Furthermore, up to 15% of severely depressed

patients will ultimately commit suicide. Suicide

attempts are up to ten per hundred subjects

depressed for a year, with one successful suicideper hundred subjects depressed for a year.


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Conclusions :

` Mood disorders are common, debilitating, life

threatening illnesses, which can be successfully

treated but which commonly are not treated.


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A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood,lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms havepersisted (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 or irrelevant external stimuli).

6. I

ncrease in goal-directed activity (either socially, at work or school, or sexually) orpsychomotor agitation.

7. Excessive involvement in pleasurable activities that have a high potential for painfulconsequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, orfoolish business investments).

C. The symptoms do not meet criteria for a mixed episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupationalfunctioning or in usual social activities or relationships with others, or to necessitatehospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e .g., a drug ofabuse, 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 diagnosisof bipolarI disorder.


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` Sex Major depression is twice as likely in women

` Age Peak age on onset is 2040 years

` Family history 1.5 to 3 times higher risk with positive history

` Marital status Separated and divorced persons report higher

ratesMarried males lower rates than unmarried

Married females higher rates than unmarried

` Postpartum An increased risk for the 6-month period

following childbirth

` Negative life events Possible association` Early parental death Possible association


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` One out of seven with recurrent depressive illness

commits suicide

` 70% of suicides have depressive illness

` 70% of suicides see their primary care physicianwithin 6 weeks of suicide

` Suicide is the seventh leading cause of death in

the United States


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` Mortality 30,000 to 35,000 suicides per year` Fatal accidents due to impaired concentration and attention

` Death due to illnesses that can be sequelae (e.g., alcohol abuse)

` Patient morbidity

` Suicide attempts

` Accidents` Resultant illnesses

` Lost jobs

` Failure to advance in career and school

` Substance abuse

`

Societal costs` Dysfunctional families

` Absenteeism

` Decreased productivity

` Job-related injuries

` Adverse effect on quality control in the workplace


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Depression and Bipolar Disorders