Lecture 8: Mood disorders

What topics are discussed?

Depression

To receive a diagnosis of depression 5 (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning. At least one of the symptoms is either 1 or two.

1. Depressed mood most of the day, nearly every day. (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain/decrease or increase in appetite nearly every day. (Note: In children, consider failure to make weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The episode is not attributable to a substance (e.g. alcohol, drugs, medication) or to another medical condition.

Mood disorder: the mood spectrum

Within mood disorders there are multiple different levels/dimensions of mood disorders. These and their characteristics will be explained.

First, there are two types of depression which can be distinguished.
A unipolar depression is characterised by just depression. Two types of unipolar depression are major depressive disorder (shorter amount of time, at least two weeks, but very severe) and dysthymic depression/persistent depressive disorder (longer amount of time, at least two years).
A bipolar disorder is characterised by periods of depression and periods of mania. There is bipolar I disorder, in which there are periods of severe depression and periods of severe mania, meanwhile in bipolar II disorder (hypomania) is characterised by less severe periods of mania. The symptoms of mania are not severe enough to interfere with daily activities and they do not consist of hallucinations or illusions.

Mania is defined as a distinct period of abnormally and persistently elevated, expansive, or irritable mood. The episode must last at least one week. The mood must have at least three of the following symptoms:

1. High self-esteem
2. Little need for sleep
3. Increased rate of speech (talking fast)
4. Flight of ideas
5. Getting easily distracted
6. An increased interest in goals or activities
7. Psychomotor agitation
8. Increased pursuit of activities with a high risk of danger

A cyclothymic depression is characterised by numerous periods of symptoms of depression and periods of hypomania. The symptoms which are shown within a person are not sufficient enough to be a major depressive episode or a hypomanic episode.

A double depression is characterised by the co-existence of major depressive disorder and persistent depressive disorder. This tends to be more severe than either MDD or PDD.

It is important to take notice of the potential existence of other disorders within a patient, for example schizophrenia or substance use disorder.

Other subtypes of depression

• Depression with anxious distress: within here anxiety symptoms are present
• Depression with mixed features: patients meet the criteria for major depressive disorder, and there are at least three symptoms for mania, but these patients do to meet all criteria for a manic episode
• Depression with psychotic features: patients also experience illusions and hallucinations
• Depression with catatonic features: patients experience catatonia, their muscles are all stiff or they keep making the same movement
• Atypical depression: patient shows a collection of different symptoms
• Postnatal depression: when women are given a diagnosis of major depressive episode during their pregnancy or within four weeks after they have given birth. 30% of the women who have given birth to a baby experience postpartum blues (lability, a lot of crying, fatigue)
• Seasonal affective disorder (SAD): experiencing symptoms of depression for at least two sequentially winters

Mood disorders and theories

Genetics play a major role in the epidemiology of mood disorders. The odds for inheriting a unipolar depression are 0.35 and for a bipolar depression 0.75.

However, one’s environment and the interaction between genetics and environment play a role as well. There are multiple risk factors which can increase the chances of developing a mood disorder. Examples of these risk factors are:

• Low socio-economic status
• Poor housing / living conditions
• Debt / poverty
• Physical ill health
• Trauma / maltreatment
• Social exclusion
• Discrimination / social inequalities

Many determinants are stress related, including trauma, parental mental illness, family conflict/violence, social exclusion, a low SES and elder abuse.

An allostatic load is the wear and tear on the body that accumulates as an individual is exposed to repeated stress. The level of stress has an effect on the performance of the body. The lower the stress levels are in the body, the less likely the allostatic load model will have a significant effect on the brain and health. However, an increase in stress levels results in an increase in stress on the brain and the health of individuals, making it more likely for the body to have significant effects on homeostasis and cause breakdown of the bodily systems.

The cognitive theory describes stressful experiences in one’s development (e.g. child abuse or trauma) influence their level of vulnerability, which can be activated by other stressful events. This exchange between these stressful experiences and one’s vulnerability can increase the likelihood of a negative cognitive bias, which can lead to a depression.

The neurotrophic theory describes how stressful experiences in one’s development can influence one’s level of vulnerability, which can lead to poor neuronal functioning, e.g. effects on memory. Neuronal plasticity is a key factor in the development of depression and in the clinical response to antidepressants.

Consequences of mood disorders

Depression is associated with suicide. If you have a group of 10 people suffering from bipolar disorder, up to 5 will try to take their own lives, from which two will succeed (20%). 15% of those with a unipolar depression will commit suicide. These numbers are big, especially when compared to the level of suicide in healthy people, which is 0.01%.

Most people that are suicidal/commit suicide have a mood disorder, but not all. Some other experience e.g. personality pathology, a psychosis, or have a substance use disorder. Other examples are choosing for assisted euthanasia.

Durkheim has developed a sociologic theory about suicide which describes three types of suicide. Egoistic suicide is committed by someone who feels abandoned by others and doesn’t have any social contacts anymore. Anomic suicide is committed by someone who has been disoriented, e.g. after losing their job. Altruistic suicide is committed by someone when he or she thinks they can help others with it (“it would be better for everyone if I wasn’t here anymore”)

A suicide cluster is spoken of when two or more suicides are linked. Explanations for this are e.g. people start relationships with those who have got the same problems as themselves, or suicide contagion: when someone else, for example a celebrity, commits suicide and ‘contaminates’ others.

What topics are discussed which aren’t discussed in the literature?

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How has this topic developed over the past few years?

An important change of criteria within the transition of DSM IV to DSM V is that in the DSM IV the death of a loved one plus a depressed mood would not be considered a depression. This is not a criterion anymore within the DSM V.

What comments are made with regard to the exam?

For semester 2, 2019/2020 the exam has been cancelled due to COVID 19. 

What questions are being asked which could be asked on the exam? What is the answer?

The healthcare provider is counseling a patient who is diagnosed with depression. Which of the following statements made by a patient should the healthcare provider recognize as a sign of transference?
A. "I am glad I lost my job because now I don't have to commute"
B. It's amazing how much you remind me of my favourite teacher"
C. I may not be good looking, but I get really good grades"
D. "I drink so I can deal with the difficult situation at work"

A patient diagnosed with major depressive disorder is admitted for inpatient care. Which of the following is the primary goal during the admission assessment? 
A. Establishing desired outcomes for the patient.
B. Administering antidepressant medications
C. Collecting and organising patient data
D. Reviewing the policies for patient conduct

A patient is admitted to an inpatient psychiatric unit because of a plan to commit suicide by taking an overdose of medication. When administering medications to this patient, which of these interventions is the priority?
A. Ensure that the patient is not 'cheeking' the medications
B. Teach the patient how to recognise adverse effects of the medications
C. Monitor the patient's vital signs before administration of medications 
D. Monitor the patient for signs of anorexia, nausea, and xerostomia

B - C - A