Depressive and Bipolar Disorders Overview

Overview of Depressive and Bipolar Disorders

• In DSM-5, depression and bipolar disorders are classified separately, unlike in DSM-IV where they were both under Mood Disorders
• Key episodes include depressive, manic, and hypomanic episodes.
• Disorders covered include: Major Depressive Disorder, Persistent Depressive Disorder, Bipolar I & II Disorders, and Cyclothymic Disorder.

Unipolar Depression Details

• DSM-5-TR lists major depressive disorder, persistent depressive disorder, and premenstrual dysphoric disorder as types of depressive disorders
• In any given year, 8% of U.S. adults experience severe unipolar depression, while 5% experience mild forms
• Approximately 20% of adults will experience unipolar depression in their lifetime
• Women in cisgender populations are twice as likely as men to have depression, and it's also more prevalent in transgender and nonbinary individuals
• The average age of onset is 19 years old, with a peak in late adolescence and early adulthood

Major Depressive Episode Checklist

• Symptoms must be present for a 2-week period
• Individuals experience an increase in depressed mood or a decrease in enjoyment/interest in activities
• Simultaneously experience at least three or four additional symptoms such as:
  • Weight or appetite changes
  • Insomnia or hypersomnia
  • Agitation or decrease in motor activity
  • Fatigue or lethargy
  • Feelings of worthlessness or excessive guilt
  • Reduced concentration or indecisiveness
  • Repetitive thoughts of death or suicide

Major Depressive Disorder (MDD) Information

• Characterized by the presence of one or more Major Depressive Episodes.
• There is no history of mania or hypomania
• It has subtype/specifiers such as seasonal pattern (usually in winter), peripartum onset (related to pregnancy), melancholic features (loss of interest), and anxious distress

Persistent Depressive Disorder Insights

• Dysthymia, is a milder but long-lasting form of depression,
• The depressed mood must persist for most of the day for at least 2 years in adults
• For children and adolescents, only 1 year of duration is required
• Additionally, at least two of the following symptoms must be present while depressed:
  • Poor appetite or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration or difficulty making decisions
  • Feelings of hopelessness
• Individuals must not have been without symptoms for more than 2 months at a time during the 2-year period
• Individuals may have a major depressive episode at some time

Biological Factors

• Genetic factors are supported by family pedigree, twin, and gene studies
• Key neurotransmitters involved: serotonin, norepinephrine, and glutamate
• Hormone and HPA pathway disruptions, specifically an overactive Hypothalamic-pituitary-adrenal HAP axis from stress, is relevant
• Dysregulation of the immune system leads to slower lymphocyte function, increased pro-inflammatory cytokines, and greater inflammation

Brain Circuitry

• Brain circuits involves the prefrontal cortex, hippocampus, amygdala, and subgenual cingulate
• Irregular activity and flow rate exists in various brain locations
• A smaller hippocampus and subgenual cingulate is observed
• Interconnectivity between brain parts often presents challenges

Biological Treatments for Depression

• Categories includes antidepressant drugs, monoamine oxidase (MAO) inhibitors, tricyclics, second-generation antidepressants, SSRIs, serotonin-norepinephrine reuptake inhibitors(SNRIs) and ketamine-based drugs
• MAO inhibitors increases serotonin and norepinephrine by inhibiting the enzyme MAO
• A special diet must be followed to avoid life-threatening side effects; these are uncommon now
• Tricyclics, found accidentally inhibit neurotransmitter reuptake to maintain neurotransmitter balance; still used as a second-line
• Selective serotonin reuptake inhibitors (SSRIs) increase serotonin without affecting other neurotransmitters and have fewer side effects but can cause weight gain and reduced sexual drive
• Examples includes Fluoxetine/Prozac, Sertraline/Zoloft, Escitalopram/Lexapro

Additional Medication and Treatments

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase both serotonin and norepinephrine activity
  • Examples are Venlafaxine/Effexor and Duloxetine/Cymbalta
• Bupropion (Wellbutrin), Mirtazapine (Remeron), and Trazodone classified as "other common medications"
• Ketamine-based antidepressants increase glutamate activity and can be administered intravenously or as a nasal spray (esketamine/Spravato), originally used as an anesthetic
• Biological brain stimulation is a treatment for depression

Brain Stimulation Techniques

• Electroconvulsive Therapy (ECT) involves electricity passed through the head, inducing a seizure ranging from 15 to 70 seconds
• The patient receives muscle relaxants or anesthetics
• Can cause memory loss, but between 50%-80% of patients show improvement
• A few other brain stimulation methods include Vagus nerve stimulation, Transcranial magnetic stimulation (TMS) and Deep brain stimulation

Bipolar Disorder

• It involves both depressive lows and manic/hypomanic highs and a shift between extremes with a dramatic impact
• Between 1-2.8% of adults have bipolar disorder, and 4.4% have it at some point
• Onset is usually between 15 and 44 years
• There are no gender differences, but higher rates are seen in low-income populations

Manic Episode Checklist

• Displaying an irregular, inflated, unrestrained, or irritable mood in addition to heightened energy or activity for at least 1 week
• Experiencing at least 3 of the following symptoms:
• Grandiosity or overblown self-esteem
• Reduced sleep need
• Increased talkativeness or drive to continue talking
• Rapidly shifting ideas or a flight of ideas
• Distractibility
• Heightened activity
• Excessive pursuit of risky activities
• Symptoms cause functional impairment, need hospitalization, or include psychotic features

Hypomanic Episode Checklist

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased activity or energy for at least 4 consecutive days
• Three (or more) of the following symptoms have persisted:
  • Inflated self-esteem or grandiosity
  • Decreased sleep need
  • More talkative or pressure to keep talking
  • Flight of ideas
  • Distractibility
  • Increase in goal-directed activity
  • Excessive involvement in activities that have a high potential for consequences
• Associated with a change in normal behavior given the individual
• Impairment is noted, but hospitalization is not necessary

Mania vs Hypomania

• Both states have many shared diagnostic criteria and involve significant functional impairment but differ in duration
• A manic episode needs a week of symptoms, versus 4 days for hypomania
• Mania often necessitates hospitalization
• Psychotic features may appear in mania, not in hypomania

Diagnosing Different Types of Bipolar Disorder

• Bipolar I disorder is diagnosed with the occurrence of a manic episode
• Hypomanic or major depressive episodes may precede or follow the manic episode, but are not required for the diagnosis
• Bipolar II disorder requires the presence or history of major depressive and hypomanic episodes but no history of a manic episode
• Mania/hypomania and depression usually alternate
• Experiencing manic and depressive symptoms concurrently is termed "mixed features".
• Having four or more of any manic, hypomanic, or depressive episodes within 12 months indicates rapid cycling

Cyclothymic Disorder Diagnostic Criteria

• Exhibiting both hypomanic and depressive symptoms for at least 2 years in adults, or 1 year in children/adolescents
• Symptoms must be present for at least half the time, with no absence of symptoms for more than 2 months
• Criteria for major depressive, manic, or hypomanic episodes have never been met
• Causing significant distress or impairment, and there is potential to shift to bipolar I or II later on

Potential causes Bipolar Disorders

• Neurotransmitter activity may be related to irregular levels of norepinephrine, serotonin, glutamate, and dopamine
• Ion activity, where improper transport of ions leads to neurons being too easily or not easily fired
• Brain structure and circuitry can show that those with bipolar disorder often experience smaller hippocampus, basal ganglia, and cerebellum and potentially bipolar-related brain circuit and irregularities
• Biological predispositions can lead to bipolar disorder
  • Twin and family pedigree studies show this connection.
• Molecular biology techniques found bipolar-related genes on 13 chromosomes

Treatments for Bipolar Disorders

• Mood stabilizing drugs such as lithium are a common solution
• The dosage should be regulated and closely analyzed to avoid toxicity
• Antiseizure drugs are slightly more tolerable than the mood stabilizers such as lithium
  • Lamotrigine (Lamictal), Carbamazepine (Tegretol), Divalproex/Valproate (Depakote)
• Antipsychotic drugs such as lithium are used to help stabilize mood

Bipolar Disorder Treatment

• Mania can be controlled well with mood stabilizers, bipolar depression is a bigger challenge
• Sometimes antidepressants can be combined with mood stabilizers, however, this can then lead to mania/hypomania
• The psychiatrist needs to be skillful with medication
• Psychotherapy itself is not helpful for bipolar disorder
• Supplemental/Adjunctive therapy is more helpful as it supports medication
• It can also encourage meditation to reduce hospitalizations
• Therapy plays a role in cyclothymic disorder treatment rather than the other forms of bipolar disorder

Cognitive-behavioral Model for Depression

• Views depression from maladaptive behaviors and dysfunctional thinking
• Negative thinking, as proposed by Beck, includes maladaptive attitudes, cognitive triad, errors, and thoughts

The Layers of Beck's Cognitive Theory

• The levels of beliefs the theory addresses are automatic thoughts, intermediate beliefs and core beliefs
• Automatic thoughts appear without being prompted
• Core beliefs are the views one has about one's self, and the world
• Intermediate beliefs include assumptions

Learned Helplessness and Depression

• According to Seligman, depression appears when the people perceive that they are unable to control reinforcements
• In attribution-helplessness, a feeling of a lack of control to prevent future negative results leads to feelings of depression

Cognitive-Behavioral Therapy for Depression

• Behavioral activation is the reintroduction to pleasurable things
• Nondepressive behavior is encouraged with reinforcement, and the reward for a depressive mindset is discouraged
• This also addresses the lack of social skills
• Beck's cognitive therapy aims to elevate modes and tackle automatic thoughts
• The goal of cognitive reconstruction is to tackle dysfunctional thoughts and develop new ones

Thoughts and Reconstruction

• First, a person needs to think through their thoughts as if they are on trial, as well as use Socratic questioning
• A thought record is a compilation of the event, the emotion and the beliefs one has
• By identifying and tackling thoughts, one is also performing decatastrophizing

Sociocultural Models for Unipolar Depression

• Depression is influenced by its society and culture
• On a family-social level, those who struggle to cope and lack intimacy often have depression tied to them
• From a multicultural outlook, both western and non-western nations deal with depression
• Non-western nations often have physical tells and cues, not from cognition.
• Those from a BIPOC backgrounds may have depressive episodes due to a lack of assistance and care

Suicide rates

• Approximately 1 million individuals die by suicide worldwide annually
• 46,000 of these occur in the United States
• Many globally (14 million) and the U.S. (1.2 million) attempted suicide or made gestures, termed parasuicide,
• Suicide is a complicated classification, and there has been talk of classing suicidal disorder, but it currently resides as a symptom, not an illness in its own right

Various Types of Suicide

• Suicide is when one inflicts death upon themselves, making the conscious decision to do so
• Subintentional death is an unconscious decision that involves actions such as drug or alchohol abuse
• Nonsuicidal self-injury (NSSI) is the destruction of one's body without the desire to die
• Around 20% of adolescents suffer those harms

Patterns found in Suicide

• There rates vary among religion
• There rates vary among gender and sexual orientation
• Suicides differs by region and countries alike
• It varies among those with relationships

Triggers for Suicide

• Stressful events, such as isolation, injury and abusive situations often spark suicidal intent
• Changes in thought stemming from hopelessness
• Alcohol and drug abuse makes such actions more likely
• Those with mental illness (70% cases in unipolar patients) may struggle

Suicide and age

• Uncommon to those of a young age.
• The numbers, however, do start to increase to adolescence and teenage years
• Its stable in adults and often decreases since midlife
• It rises again once reaching older adults

Therapeutic goals for suicidal patients:

• The primary goal is to keep patients alive
• Reduce psychological pain
• Help patients attain a nonsuicidal thought process and mindset to prevent it
• Lessening the means of getting to lethal weapons and techniques
• Teach them new stress management solutions

Suicide prevention

• Crisis intervention and suicide hotlines is a great suicide prevention method
• It is often answered and operated with professional assistance
• There are over 200 in the USA
• Often come in the form of a suicide and crisis lifeline that connect those is need to professional help
• Often there are community referrals and resources

The Goals and Steps of Suicide Prevention

• First, establish a connection and safe relationship
• Understand the potential issue or struggle they may entail
• Determine the best means or actions to take with resources
• Often there is an emergency resource and safety plan involved
• Community and Public awareness is pushed as well