Mood Disorders:  Depression, Mania, & Bipolar Disorder
What is Mood?  <ul><li>“ Mood is a  a conscious state of mind or predominant emotion”  </li></ul><ul><li>Webster’s Diction...
What is a Mood Disorder?  <ul><li>Involves disabling disturbances in emotions that are markedly different from normal func...
Types of Mood Disorders <ul><li>Main Distinction: unipolar or bipolar </li></ul><ul><ul><li>Unipolar: only one end of the ...
Bipolar Disorders <ul><li>Bipolar I Disorder </li></ul><ul><li>Bipolar II Disorder </li></ul><ul><li>Cyclothymic Disorder ...
Manic Episode: DSM Criteria   <ul><li>A distinct period of abnormally and persistently elevated, expansive, or irritable m...
Manic Episode Rule-Outs <ul><li>do not meet criteria for a Mixed Episode  </li></ul><ul><ul><li>Mixed episode = both manic...
Bipolar I  <ul><li>1 or more manic episodes; may have had past depressive episodes or not </li></ul><ul><li>Lifetime Preva...
Bipolar II <ul><li>recurrent major depressive episodes with hypomanic episodes </li></ul><ul><ul><li>Hypomania - All the c...
Bipolar Disorder <ul><li>Bipolar I </li></ul><ul><li>Alternation of full manic and depressive episodes </li></ul><ul><li>A...
Cyclothymia <ul><li>For at least two years (one year for children and adolescents) presence of numerous hypomanic episodes...
Mania Etiology <ul><li>better-suited for the biological model  </li></ul><ul><ul><li>not normally distributed in the popul...
What Does Mania Look Like?   Client 1: Mary
 
Depressive Disorders <ul><li>Major Depressive Disorder (single, recurrent) </li></ul><ul><li>[Major Depressive Disorder: P...
What Does Depression Look Like?  <ul><ul><li>Sadness </li></ul></ul><ul><ul><li>Suicidal Thoughts </li></ul></ul><ul><ul><...
Depressive Episode/Disorder:   DSM Criteria   <ul><li>Five or more of the following during the same 2-week period that rep...
Depression Diagnosis  Rule-Outs <ul><li>The symptoms do not meet criteria for a Mixed Episode  </li></ul><ul><li>The sympt...
Major Depression <ul><li>MDD, Single episode </li></ul><ul><li>Absence of mania or hypomania </li></ul><ul><li>MDD, Recurr...
Dysthymic Disorder: Symptoms <ul><li>Depressed/irritable mood </li></ul><ul><li>Presence of two of the following: </li></u...
“Double Depression” <ul><li>Not a diagnosis </li></ul><ul><li>Meet diagnostic criteria for both MDD and Dysthymic Disorder...
Prevalence <ul><li>Point prevalence  is the percentage of the population who have the disorder at a particular time or ove...
Facts About Depression  <ul><li>Major depression is the single most common psychiatric disorder in the U.S.  </li></ul><ul...
What Does Depression  Look Like?   Client 1: Mary  Client 2: Barbara  Client 3: Evelyn
Video Reactions?  <ul><li>What symptoms of depression did you notice in these clients?  </li></ul><ul><li>Any evidence of ...
Etiology: Biological <ul><li>Genetic Factors </li></ul><ul><ul><li>Family, twin, and adoption studies suggest that depress...
Etiology: Biological cont. <ul><li>Adoption studies  </li></ul><ul><ul><li>More mood disorders occur in the biological rel...
Etiology: Biological Con’t <ul><li>Neurochemical Factors </li></ul><ul><ul><li>Neurotransmitters </li></ul></ul><ul><ul><u...
Research on Neurotransmitters <ul><li>norepinephrine & serotonin </li></ul><ul><ul><li>Implicated in mania and depression ...
Beck’s Cognitive Theory of Depression <ul><li>distortions of reality & depressogenic cognitions result in depression  </li...
Cognitive Theory Con’t <ul><li>negative automatic thoughts  </li></ul><ul><ul><li>further bias that individuals’ view of h...
Helplessness/Hopelessness Model <ul><li>Seligman’s learned helplessness model started as a conditioning model with dogs  <...
Attributional Model <ul><li>Abramson - Attribution of lack of control over stress leads to anxiety and depression </li></u...
Seligman and Beck <ul><li>Seligman </li></ul><ul><li>Attributions are: </li></ul><ul><li>Internal </li></ul><ul><li>Stable...
Attributional Model Con’t <ul><li>Internal - attribute negative events to own failings </li></ul><ul><li>Stable - belief t...
Major Depression: Social and Cultural Factors <ul><li>Stressful life events </li></ul><ul><li>Social support (marital rela...
Marital Status and MDD Percentage w/MDD
Ethnicity and Prevalence of MDD Percentage by Ethnicity
Gender Differences in Depression  <ul><li>Dr. Susan Nolen-Hoeksema </li></ul><ul><li>Women diagnosed twice as often as men...
Diathesis-Stress Model <ul><li>Neither biological nor environmental and personal factors alone can produce depression  </l...
Diathesis-Stress Example No Life Event Life Event  Depression Low NE Normal NE
Comorbidity with Anxiety   <ul><li>distinguishing depression from anxiety difficult </li></ul><ul><li>Watson & Clark: trip...
Psychological Treatments for Depression  <ul><li>Psychodynamic Therapies </li></ul><ul><li>Cognitive-Behavioral Therapies ...
Cognitive Therapy Procedures 16 weeks of treatment Extensive Assessment: Placebo & Clinical Management Depression Collabor...
Biological Therapies for Depression  <ul><li>Drug Therapies </li></ul><ul><ul><li>Tricyclics </li></ul></ul><ul><ul><li>Se...
Mood Disorders: Prevalence <ul><li>Disorders </li></ul><ul><li>Major Depression </li></ul><ul><li>Dysthymia </li></ul><ul>...
Suicide <ul><li>8 th  leading cause of death in the U.S. </li></ul><ul><li>Overwhelmingly white phenomena </li></ul><ul><l...
5 Myths and Facts About Suicide <ul><li>Myth #1 : </li></ul><ul><li>People who talk about killing themselves rarely commit...
5 Myths and Facts About Suicide <ul><li>Myth #2: </li></ul><ul><li>The suicidal person wants to die and feels there is no ...
5 Myths and Facts About Suicide <ul><li>Myth # 3: </li></ul><ul><li>If you ask someone about their suicidal intentions, yo...
5 Myths and Facts About Suicide <ul><li>Myth # 4: </li></ul><ul><li>All suicidal people are deeply depressed. </li></ul><u...
5 Myths and Facts About Suicide <ul><li>Myths # 5: </li></ul><ul><li>Suicidal people rarely seek medical attention. </li><...
Sociodemographic Risk Factors <ul><li>Male </li></ul><ul><li>> 60 years </li></ul><ul><li>Widowed or Divorced </li></ul><u...
Clinical Risk Factors <ul><li>Previous Attempts </li></ul><ul><li>Clinical depression or schizophrenia </li></ul><ul><li>S...
Assessing Risk and Planning Intervention Safety Plan Remove Lethal Items Hospitalize Intent to die Increased Specific leth...
Commonalities of Suicide  (Schneiderman, 1985) <ul><li>purpose is to seek a solution.  </li></ul><ul><li>goal is the cessa...
Clinical Considerations of Suicide Assessment <ul><li>For those who are reluctant to assess suicide: </li></ul><ul><li>Ask...
Suicide:Treatment <ul><li>Problem-solving  </li></ul><ul><li>Cognitive behavioral therapy </li></ul><ul><li>Coping skills ...
Postpartum Depression
Burden <ul><li>In the United States, depression is the leading cause of non-obstetric hospitalizations among women aged 18...
Perinatal Depression: Prevalence 9.2% 13.6% Evans et al., 2001 10.4% 7.7% O’Hara et al., 1990 8.7% 6.0% Cooper et al. 1988...
Postpartum Blues <ul><li>Most common, 50-80% </li></ul><ul><li>Relatively brief </li></ul><ul><ul><li>Few hours to several...
Typical Blues Symptoms <ul><li>Low Mood </li></ul><ul><li>Mood Lability </li></ul><ul><li>Insomnia </li></ul><ul><li>Anxie...
Postpartum Psychosis <ul><li>Rare:  1/1000 postpartum women </li></ul><ul><li>Hallucinations and/or Delusions </li></ul><u...
Postpartum Psychosis   <ul><li>Usually Begins Within 90 Days Postpartum </li></ul><ul><li>Length is Quite Variable </li></...
Postpartum Depression <ul><li>Not as mild or transient as the blues </li></ul><ul><li>Not as severely disorienting as psyc...
Postpartum Depression: Risk Factors <ul><li>Lower SES/unemployment </li></ul><ul><li>Past depression or anxiety disorder <...
Effects of Perinatal Depression: An Overview   <ul><li>Depression negatively effects: </li></ul><ul><li>Mother’s ability t...
Postpartum Depression: Maternal Attitudes <ul><ul><li>Infants perceived to be more bothersome </li></ul></ul><ul><ul><li>M...
Postpartum Depression: Maternal Behaviors <ul><li>Gaze less at their infants </li></ul><ul><li>Take longer to respond to i...
Postpartum Depression: Maternal Interactions <ul><li>Flat affect, low activity level, and lack of contingent responding </...
Effects of Maternal Depression <ul><li>Infants- lowered Brazelton scores, frequent looking away, fussiness </li></ul><ul><...
What Can Be Done? <ul><li>ROUTINE SCREENING </li></ul><ul><li>REFERRAL TO TREATMENT </li></ul>
Why Screen for Perinatal Depression?   <ul><li>Screening is associated with increased detection </li></ul><ul><li>Georgiop...
Barriers to Detection <ul><li>Women will present themselves as well as they are ashamed and embarrassed to admit that they...
Barriers to Detection <ul><li>Women will present themselves as well as they are ashamed and embarrassed to admit that they...
 
 
 
Barriers to Detection (cont) <ul><li>Lack of knowledge about range of postpartum disorders </li></ul><ul><li>They don’t wa...
“ I Was Depressed But Didn’t Know It.” <ul><li>Commonalities in the Experience of Non-depressed and Depressed Pregnant and...
What is Required for Effective Screening? <ul><li>What to do with a positive screen? </li></ul><ul><ul><li>Implement or re...
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Mood Disorders: Depression, Mania,

  1. 1. Mood Disorders: Depression, Mania, & Bipolar Disorder
  2. 2. What is Mood? <ul><li>“ Mood is a a conscious state of mind or predominant emotion” </li></ul><ul><li>Webster’s Dictionary </li></ul>
  3. 3. What is a Mood Disorder? <ul><li>Involves disabling disturbances in emotions that are markedly different from normal functioning </li></ul><ul><li>Can also include cognitive & behavioral disturbances </li></ul><ul><li>Generally occurs in discrete episodes </li></ul><ul><ul><li>Depression – extreme sadness </li></ul></ul><ul><ul><li>Mania – extreme elation and irritability </li></ul></ul>
  4. 4. Types of Mood Disorders <ul><li>Main Distinction: unipolar or bipolar </li></ul><ul><ul><li>Unipolar: only one end of the emotion spectrum </li></ul></ul><ul><ul><ul><li>Major Depressive Episode </li></ul></ul></ul><ul><ul><ul><li>Manic Episode </li></ul></ul></ul><ul><ul><li>Bipolar: cycling between both ends of the emotion spectrum </li></ul></ul><ul><ul><ul><li>Bipolar Disorder </li></ul></ul></ul><ul><li>Other Disorders </li></ul><ul><ul><li>Dysthymia: mild, chronic form of depression </li></ul></ul><ul><ul><li>Cyclothymia: similar to bipolar, but a more mild form of mania (hypomania) </li></ul></ul>
  5. 5. Bipolar Disorders <ul><li>Bipolar I Disorder </li></ul><ul><li>Bipolar II Disorder </li></ul><ul><li>Cyclothymic Disorder </li></ul>
  6. 6. Manic Episode: DSM Criteria <ul><li>A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). </li></ul><ul><li>During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: </li></ul><ul><li>(1) inflated self-esteem or grandiosity </li></ul><ul><li>(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) </li></ul><ul><li>(3) more talkative than usual or pressure to keep talking </li></ul><ul><li>(4) flight of ideas or subjective experience that thoughts are racing </li></ul><ul><li>(5) distractibility (i.e., attention too easily drawn to unimportant stimuli) </li></ul><ul><li>(6) increase in goal-directed activity or psychomotor agitation </li></ul><ul><li>(7) excessive involvement in pleasurable activities that have a high potential for painful consequences </li></ul>
  7. 7. Manic Episode Rule-Outs <ul><li>do not meet criteria for a Mixed Episode </li></ul><ul><ul><li>Mixed episode = both manic and depressed nearly everyday for at least one week </li></ul></ul><ul><li>marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features </li></ul><ul><li>not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism) </li></ul><ul><li>Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder </li></ul>
  8. 8. Bipolar I <ul><li>1 or more manic episodes; may have had past depressive episodes or not </li></ul><ul><li>Lifetime Prevalence : about 1%; equal in men and women </li></ul><ul><li>Course and Prognosis : poorer prognosis than MDD </li></ul><ul><ul><li>45% have one more episode </li></ul></ul><ul><ul><li>only 50-60% achieve control over Sx with lithium </li></ul></ul><ul><ul><li>40% develop a chronic disorder </li></ul></ul>
  9. 9. Bipolar II <ul><li>recurrent major depressive episodes with hypomanic episodes </li></ul><ul><ul><li>Hypomania - All the criteria of a Manic episode except criterion C (marked impairment) </li></ul></ul><ul><ul><li>NOT full-blown manic episodes, if an individual does experience a manic episode, they are then diagnosed with Bipolar I Disorder </li></ul></ul><ul><li>matter of differential diagnosis </li></ul>
  10. 10. Bipolar Disorder <ul><li>Bipolar I </li></ul><ul><li>Alternation of full manic and depressive episodes </li></ul><ul><li>Average onset is 18 years </li></ul><ul><li>Tends to be chronic </li></ul><ul><li>High risk for suicide </li></ul><ul><li>Bipolar II </li></ul><ul><li>Alternation of Major Depression with hypomania </li></ul><ul><li>Average onset is 22 years </li></ul><ul><li>Tends to be chronic </li></ul><ul><li>10% progess to full biploar I disorder </li></ul>
  11. 11. Cyclothymia <ul><li>For at least two years (one year for children and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depression </li></ul><ul><li>During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a time </li></ul><ul><li>No evidence of MDD or Manic episode during the first two years of disturbance </li></ul><ul><li>No psychotic disorder </li></ul><ul><li>No organic cause </li></ul>
  12. 12. Mania Etiology <ul><li>better-suited for the biological model </li></ul><ul><ul><li>not normally distributed in the population </li></ul></ul><ul><ul><li>Symptoms are very marked and severe </li></ul></ul><ul><li>not necessarily precipitated by a positive life event & can override negative events </li></ul><ul><ul><li>further evidence in favor of diathesis </li></ul></ul><ul><li>Familial Pattern seen </li></ul><ul><li>Twin and adoption studies </li></ul>
  13. 13. What Does Mania Look Like? Client 1: Mary
  14. 15. Depressive Disorders <ul><li>Major Depressive Disorder (single, recurrent) </li></ul><ul><li>[Major Depressive Disorder: Postpartum onset]** </li></ul><ul><li>Dysthymic Disorder </li></ul><ul><li>Double Depression </li></ul><ul><li>Postpartum depression as a specifier </li></ul>
  15. 16. What Does Depression Look Like? <ul><ul><li>Sadness </li></ul></ul><ul><ul><li>Suicidal Thoughts </li></ul></ul><ul><ul><li>Tiredness </li></ul></ul><ul><ul><li>Boredom </li></ul></ul><ul><ul><li>Unwilling to get out </li></ul></ul><ul><ul><li>Insomnia </li></ul></ul>
  16. 17. Depressive Episode/Disorder: DSM Criteria <ul><li>Five or more of the following during the same 2-week period that represent a change from usual functioning including either (1) depressed mood or (2) loss of interest. </li></ul><ul><li>Sad, depressed mood, most of the day, nearly every day for two weeks </li></ul><ul><li>Loss of interest and pleasure in usual activities </li></ul><ul><li>Difficulties sleeping </li></ul><ul><li>Shift in activity level </li></ul><ul><li>Changes in appetite and weight loss/gain </li></ul><ul><li>Loss of energy, fatigue </li></ul><ul><li>Negative self-concept, self-blame, guilt, worthlessness </li></ul><ul><li>Difficulty concentrating </li></ul><ul><li>Recurrent thoughts of death or suicide </li></ul>
  17. 18. Depression Diagnosis Rule-Outs <ul><li>The symptoms do not meet criteria for a Mixed Episode </li></ul><ul><li>The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). </li></ul><ul><li>The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. </li></ul>
  18. 19. Major Depression <ul><li>MDD, Single episode </li></ul><ul><li>Absence of mania or hypomania </li></ul><ul><li>MDD, Recurrent </li></ul><ul><li>2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood </li></ul>
  19. 20. Dysthymic Disorder: Symptoms <ul><li>Depressed/irritable mood </li></ul><ul><li>Presence of two of the following: </li></ul><ul><li>Appetite disturbance </li></ul><ul><li>Sleep disturbance </li></ul><ul><li>Low energy/fatigue </li></ul><ul><li>Poor concentration of difficulties making decision </li></ul><ul><li>Feelings of hopelessness </li></ul><ul><li>C. Present for two year period (one year in children and adolescents) </li></ul><ul><li>D. No evidence of a Major Depressive Epidsode during the first two years (one year for children) </li></ul><ul><li>E. No manic or hypomanic episode </li></ul><ul><li>F. No chronic psychotic disorder </li></ul><ul><li>G. Not related to organic factors </li></ul>
  20. 21. “Double Depression” <ul><li>Not a diagnosis </li></ul><ul><li>Meet diagnostic criteria for both MDD and Dysthymic Disorder </li></ul>
  21. 22. Prevalence <ul><li>Point prevalence is the percentage of the population who have the disorder at a particular time or over a given period of time. </li></ul><ul><li>Lifetime prevalence is the percentage of individuals who have ever had a specific disorder at any time. </li></ul>
  22. 23. Facts About Depression <ul><li>Major depression is the single most common psychiatric disorder in the U.S. </li></ul><ul><li>The point prevalence rate over a 1-year period is 8% for men and 13% for women. </li></ul><ul><li>Lifetime prevalence rate is 12.7% for men and 21.3% for women. </li></ul><ul><li>In addition, depression is the most common factor leading to suicide. </li></ul>
  23. 24. What Does Depression Look Like? Client 1: Mary Client 2: Barbara Client 3: Evelyn
  24. 25. Video Reactions? <ul><li>What symptoms of depression did you notice in these clients? </li></ul><ul><li>Any evidence of suicidal thoughts? </li></ul><ul><li>Which patient might be more likely to commit suicide? Why? </li></ul>
  25. 26. Etiology: Biological <ul><li>Genetic Factors </li></ul><ul><ul><li>Family, twin, and adoption studies suggest that depression in hereditary </li></ul></ul><ul><ul><li>More severe the depression in an individual, more likely that relative have depression as well </li></ul></ul><ul><ul><li>MDD concordance: 40% MZ, 10% DZ </li></ul></ul><ul><ul><li>Mania concordance: 75% MZ, 25% DZ </li></ul></ul><ul><ul><li>Severity of disorder is due to strength of genetic loading </li></ul></ul>
  26. 27. Etiology: Biological cont. <ul><li>Adoption studies </li></ul><ul><ul><li>More mood disorders occur in the biological relatives of those with mood disorders </li></ul></ul><ul><ul><li>both unipolar and bipolar disorders </li></ul></ul><ul><ul><li>severity linked to the strength of the genetic loading </li></ul></ul>
  27. 28. Etiology: Biological Con’t <ul><li>Neurochemical Factors </li></ul><ul><ul><li>Neurotransmitters </li></ul></ul><ul><ul><ul><li>Norepinephrine </li></ul></ul></ul><ul><ul><ul><li>Serotonin </li></ul></ul></ul><ul><ul><ul><li>Dopamine </li></ul></ul></ul><ul><ul><ul><ul><li>Not clear what processes are dysfunctional (production, reuptake, chemical breakdown, etc.) </li></ul></ul></ul></ul><ul><ul><li>Neuroendocrine changes </li></ul></ul><ul><ul><ul><li>Hypothyroidisim </li></ul></ul></ul>
  28. 29. Research on Neurotransmitters <ul><li>norepinephrine & serotonin </li></ul><ul><ul><li>Implicated in mania and depression </li></ul></ul><ul><li>effectiveness of antidepressants </li></ul><ul><ul><li>most drugs in psychiatry discovered by accident </li></ul></ul><ul><li>Not as simple a relationship as previously thought </li></ul><ul><ul><li>E.g. TCA and MAOI drugs </li></ul></ul><ul><li>Permissive hypothesis </li></ul>
  29. 30. Beck’s Cognitive Theory of Depression <ul><li>distortions of reality & depressogenic cognitions result in depression </li></ul><ul><li>schema filters and organizes experiences to store beliefs and knowledge about ourselves </li></ul><ul><li>cognitive triad of negative schemas </li></ul><ul><ul><li>negative view of the self, the world, and the future </li></ul></ul>
  30. 31. Cognitive Theory Con’t <ul><li>negative automatic thoughts </li></ul><ul><ul><li>further bias that individuals’ view of himself, the world, and the future </li></ul></ul><ul><ul><li>e.g., arbitrary inference, selective abstraction, overgeneralization, magnification, etc. </li></ul></ul><ul><li>thoughts focused on experiences of loss and failure </li></ul><ul><li>research supports the presence of distorted, automatic cognitions </li></ul><ul><ul><li>the causal relationship of these factors not established </li></ul></ul>
  31. 32. Helplessness/Hopelessness Model <ul><li>Seligman’s learned helplessness model started as a conditioning model with dogs </li></ul><ul><li>those who were exposed to uncontrollable aversive situations would develop depression that was rooted in feelings of helplessness </li></ul>
  32. 33. Attributional Model <ul><li>Abramson - Attribution of lack of control over stress leads to anxiety and depression </li></ul><ul><li>Cognitive distortions affect the interpretation of causes of events in people’s lives. </li></ul><ul><li>biased attributional style (i.e., a cognitive style regarding beliefs about the causes of events) characterized by internal, stable, and global attributions. </li></ul>
  33. 34. Seligman and Beck <ul><li>Seligman </li></ul><ul><li>Attributions are: </li></ul><ul><li>Internal </li></ul><ul><li>Stable </li></ul><ul><li>Global </li></ul><ul><li>I am inadequate (internal) at everything (global) and I always will be (stable). </li></ul><ul><li>“ Dark glasses about why things are bad” </li></ul><ul><li>Interpretation (theory) </li></ul><ul><li>Beck </li></ul><ul><li>Negative interpretations about: </li></ul><ul><li>Themselves </li></ul><ul><li>Immediate world (their place) </li></ul><ul><li>Future (their place) </li></ul><ul><li>I am not good at school (self). I hate this campus (world). Things are not going to go well in college (future). </li></ul><ul><li>“ Dark glasses about what is going on” </li></ul><ul><li>Description </li></ul>
  34. 35. Attributional Model Con’t <ul><li>Internal - attribute negative events to own failings </li></ul><ul><li>Stable - belief that causes of negative events remain constant </li></ul><ul><li>Global - assume causes of negative events have broad and general effects </li></ul><ul><li>research supports the hopelessness model </li></ul><ul><ul><li>but cannot establish causal relationship </li></ul></ul>
  35. 36. Major Depression: Social and Cultural Factors <ul><li>Stressful life events </li></ul><ul><li>Social support (marital relationship) (see chart) </li></ul><ul><li>Gender </li></ul><ul><li>Culture (see chart) </li></ul>
  36. 37. Marital Status and MDD Percentage w/MDD
  37. 38. Ethnicity and Prevalence of MDD Percentage by Ethnicity
  38. 39. Gender Differences in Depression <ul><li>Dr. Susan Nolen-Hoeksema </li></ul><ul><li>Women diagnosed twice as often as men </li></ul><ul><li>difference not evident in childhood </li></ul><ul><ul><li>boys and girls are just as likely to experience depression </li></ul></ul><ul><ul><li>Changes in preteen years </li></ul></ul><ul><li>What factors may be involved in the development of these differences? </li></ul>
  39. 40. Diathesis-Stress Model <ul><li>Neither biological nor environmental and personal factors alone can produce depression </li></ul><ul><li>a biological vulnerability (or diathesis) interacts with life stressors to produce depression </li></ul><ul><ul><li>For example, a neurotransmitter dysfunction may interact with life stressors (e.g., death of a loved one) to produce depression </li></ul></ul>
  40. 41. Diathesis-Stress Example No Life Event Life Event Depression Low NE Normal NE
  41. 42. Comorbidity with Anxiety <ul><li>distinguishing depression from anxiety difficult </li></ul><ul><li>Watson & Clark: tripartite model </li></ul><ul><ul><li>Negative affectivity (NA) - pervasive individual differences in negative emotionality and self-concept </li></ul></ul><ul><ul><ul><li>Common to anxiety & depression </li></ul></ul></ul><ul><ul><li>Anhedonia - lack of experiencing pleasure </li></ul></ul><ul><ul><ul><li>specific to depression </li></ul></ul></ul><ul><ul><li>Anxious arousal - physiological symptoms of anxiety </li></ul></ul><ul><ul><ul><li>specific to anxiety disorders </li></ul></ul></ul>
  42. 43. Psychological Treatments for Depression <ul><li>Psychodynamic Therapies </li></ul><ul><li>Cognitive-Behavioral Therapies </li></ul><ul><ul><li>Beck Cognitive Therapy </li></ul></ul><ul><ul><li>Social Skills Training </li></ul></ul><ul><ul><li>Behavioral Activation </li></ul></ul><ul><li>Interpersonal Therapy </li></ul>
  43. 44. Cognitive Therapy Procedures 16 weeks of treatment Extensive Assessment: Placebo & Clinical Management Depression Collaborative Research Program Interpersonal Psychotherapy T Treatment Groups Outcome Measures Depressive Symptoms Overall symptomotology and life functioning Functioning in treatment specific domains <ul><li>Results: </li></ul><ul><li>Post-Treatment </li></ul><ul><li>Equivalent success in three active treatments over placebo </li></ul><ul><li>Medication was faster </li></ul><ul><li>IPT better than CBT for more severely depressed patients </li></ul><ul><li>Particular treatments effected change in expected domains </li></ul><ul><li>Results </li></ul><ul><li>Follow-up-18 months </li></ul><ul><li>Equivalent success in three active treatments </li></ul><ul><li>Only 20 to 30% of recovered patients were still well </li></ul><ul><li>Patients in IPT report more satisfaction with treatment </li></ul><ul><li>IPT and CBT patients more likely to report that treatment affected capacity to establish and maintain relationships and to understand source of their depression </li></ul>Medication Imiprimine Many Controversial Issues
  44. 45. Biological Therapies for Depression <ul><li>Drug Therapies </li></ul><ul><ul><li>Tricyclics </li></ul></ul><ul><ul><li>Selective serotonin reuptake inhibitors </li></ul></ul><ul><ul><li>Monoamine oxidase inhibitors </li></ul></ul><ul><li>Electroconvulsive Therapy </li></ul>
  45. 46. Mood Disorders: Prevalence <ul><li>Disorders </li></ul><ul><li>Major Depression </li></ul><ul><li>Dysthymia </li></ul><ul><li>Bipolar I </li></ul><ul><li>Bipolar II </li></ul><ul><li>MDD (Postpartum) </li></ul><ul><li>Prevalence </li></ul><ul><li>4.9% </li></ul><ul><li>3.2% </li></ul><ul><li>0.8% </li></ul><ul><li>0.5 </li></ul><ul><li>13% </li></ul>
  46. 47. Suicide <ul><li>8 th leading cause of death in the U.S. </li></ul><ul><li>Overwhelmingly white phenomena </li></ul><ul><li>Suicide rates also quite high in Native American </li></ul><ul><li>Rate of suicide is increasing in adolescents and elderly </li></ul><ul><li>Males are more likely to commit suicide </li></ul><ul><li>Females are more likely to attempt suicide (except China) </li></ul>
  47. 48. 5 Myths and Facts About Suicide <ul><li>Myth #1 : </li></ul><ul><li>People who talk about killing themselves rarely commit suicide. </li></ul><ul><li>Fact: </li></ul><ul><li>Most people who commit suicide have given some verbal clues or warnings of their intentions </li></ul>
  48. 49. 5 Myths and Facts About Suicide <ul><li>Myth #2: </li></ul><ul><li>The suicidal person wants to die and feels there is no turning back. </li></ul><ul><li>Fact: </li></ul><ul><li>Suicidal people are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems. </li></ul>
  49. 50. 5 Myths and Facts About Suicide <ul><li>Myth # 3: </li></ul><ul><li>If you ask someone about their suicidal intentions, you will only encourage them to kill themselves. </li></ul><ul><li>Fact: </li></ul><ul><li>The opposite is true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment. </li></ul>
  50. 51. 5 Myths and Facts About Suicide <ul><li>Myth # 4: </li></ul><ul><li>All suicidal people are deeply depressed. </li></ul><ul><li>Fact: </li></ul><ul><li>Although depression is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree. </li></ul>
  51. 52. 5 Myths and Facts About Suicide <ul><li>Myths # 5: </li></ul><ul><li>Suicidal people rarely seek medical attention. </li></ul><ul><li>Fact: </li></ul><ul><li>75% of suicidal individuals will visit a physician within the month before they kill themselves. </li></ul>
  52. 53. Sociodemographic Risk Factors <ul><li>Male </li></ul><ul><li>> 60 years </li></ul><ul><li>Widowed or Divorced </li></ul><ul><li>White or Native American </li></ul><ul><li>Living alone (social isolation) </li></ul><ul><li>Unemployed (financial difficulties) </li></ul><ul><li>Recent adverse life events </li></ul><ul><li>Chronic Illness </li></ul>
  53. 54. Clinical Risk Factors <ul><li>Previous Attempts </li></ul><ul><li>Clinical depression or schizophrenia </li></ul><ul><li>Substance Abuse </li></ul><ul><li>Feelings of hopelessness </li></ul><ul><li>Severe anxiety, particularly with depression </li></ul><ul><li>Severe loss of interest in usual activities </li></ul><ul><li>Impaired thought process </li></ul><ul><li>Impulsivity </li></ul>
  54. 55. Assessing Risk and Planning Intervention Safety Plan Remove Lethal Items Hospitalize Intent to die Increased Specific lethal plan Extreme Safety Plan Remove Lethal Items None Increased Specific lethal plan Severe Safety Plan None Increased Vague Plan/low lethal Mod. Safety Plan None Few No Low Interven. Severity Intent Risk Factors Specific Plan Risk Level
  55. 56. Commonalities of Suicide (Schneiderman, 1985) <ul><li>purpose is to seek a solution. </li></ul><ul><li>goal is the cessation of consciousness (not death). </li></ul><ul><li>stimulus is intolerable psychological pain. </li></ul><ul><li>stressor is frustrated psychological needs. </li></ul><ul><li>emotion is hopelessness-helplessness. </li></ul><ul><li>cognitive state is ambivalence. </li></ul><ul><li>perceptual state is constriction. </li></ul><ul><li>action is egression. </li></ul><ul><li>interpersonal act is communication of intention. </li></ul><ul><li>consistency is with lifelong coping patterns. </li></ul>
  56. 57. Clinical Considerations of Suicide Assessment <ul><li>For those who are reluctant to assess suicide: </li></ul><ul><li>Asking questions may feel intrusive but not asking has dangerous consequences </li></ul><ul><li>A calm and genuinely concerned approach is effective </li></ul>
  57. 58. Suicide:Treatment <ul><li>Problem-solving </li></ul><ul><li>Cognitive behavioral therapy </li></ul><ul><li>Coping skills </li></ul><ul><li>Stress reduction </li></ul>
  58. 59. Postpartum Depression
  59. 60. Burden <ul><li>In the United States, depression is the leading cause of non-obstetric hospitalizations among women aged 18-44. </li></ul><ul><li>In the year 2000, 205,000 women aged 18-44 were discharged with a diagnosis of depression. </li></ul><ul><li>Seven percent of all hospitalizations among young women were for depression. </li></ul>
  60. 61. Perinatal Depression: Prevalence 9.2% 13.6% Evans et al., 2001 10.4% 7.7% O’Hara et al., 1990 8.7% 6.0% Cooper et al. 1988 12.0% 9.0% O’Hara et al., 1984 12.0% 9.4% Watson & Elliott 1984 14.9% 13.4% Kumar & Robeson 1984 Postpartum Pregnancy
  61. 62. Postpartum Blues <ul><li>Most common, 50-80% </li></ul><ul><li>Relatively brief </li></ul><ul><ul><li>Few hours to several days </li></ul></ul><ul><li>Onset usually in first week to 10 days PP </li></ul><ul><li>Typically remit spontaneously </li></ul><ul><ul><li>May represent the initial stages of PPD/PPP </li></ul></ul>
  62. 63. Typical Blues Symptoms <ul><li>Low Mood </li></ul><ul><li>Mood Lability </li></ul><ul><li>Insomnia </li></ul><ul><li>Anxiety </li></ul><ul><li>Crying </li></ul><ul><li>Irritability </li></ul>
  63. 64. Postpartum Psychosis <ul><li>Rare: 1/1000 postpartum women </li></ul><ul><li>Hallucinations and/or Delusions </li></ul><ul><li>Risk Factors: </li></ul><ul><ul><ul><li>History Bipolar Affective Disorder/Psychosis </li></ul></ul></ul><ul><ul><ul><li>Family history of psychosis </li></ul></ul></ul><ul><ul><ul><li>Having first child </li></ul></ul></ul><ul><li>Aggressive intervention absolutely necessary </li></ul>
  64. 65. Postpartum Psychosis <ul><li>Usually Begins Within 90 Days Postpartum </li></ul><ul><li>Length is Quite Variable </li></ul><ul><li>Prevalence: 1/500 to 1/1000 </li></ul><ul><li>Family history of bipolar disorder 33/1000 </li></ul><ul><li>Family history of postpartum psychosis 22/1000 </li></ul><ul><li>Personal history bipolar disorder: 1/2 </li></ul><ul><li>Sequelae: Future Postpartum Psychosis </li></ul>
  65. 66. Postpartum Depression <ul><li>Not as mild or transient as the blues </li></ul><ul><li>Not as severely disorienting as psychosis </li></ul><ul><li>Range of severity </li></ul><ul><li>Often undetected </li></ul>
  66. 67. Postpartum Depression: Risk Factors <ul><li>Lower SES/unemployment </li></ul><ul><li>Past depression or anxiety disorder </li></ul><ul><li>Past history of alcohol abuse </li></ul><ul><li>Stressful life-events </li></ul><ul><li>Poor marital relationship </li></ul><ul><li>Inadequate social support </li></ul><ul><li>Child-care related stressors </li></ul><ul><li>African American ethnicity </li></ul>
  67. 68. Effects of Perinatal Depression: An Overview <ul><li>Depression negatively effects: </li></ul><ul><li>Mother’s ability to mother </li></ul><ul><li>Mother—infant relationship </li></ul><ul><li>Emotional and cognitive development of the child </li></ul>
  68. 69. Postpartum Depression: Maternal Attitudes <ul><ul><li>Infants perceived to be more bothersome </li></ul></ul><ul><ul><li>Make harsh judgments of their infants </li></ul></ul><ul><ul><li>Feelings of guilt, resentment, and ambivalence toward child </li></ul></ul><ul><ul><li>Loss of affection toward child </li></ul></ul>
  69. 70. Postpartum Depression: Maternal Behaviors <ul><li>Gaze less at their infants </li></ul><ul><li>Take longer to respond to infant’s utterances </li></ul><ul><li>Show fewer positive facial expressions </li></ul><ul><li>Lack awareness of their infants </li></ul><ul><li>Increased risk for abusing children </li></ul>
  70. 71. Postpartum Depression: Maternal Interactions <ul><li>Flat affect, low activity level, and lack of contingent responding </li></ul><ul><li>OR </li></ul><ul><li>Alternating disengagement and intrusiveness </li></ul>
  71. 72. Effects of Maternal Depression <ul><li>Infants- lowered Brazelton scores, frequent looking away, fussiness </li></ul><ul><li>Toddlers- poorer cognitive development, insecure attachment </li></ul><ul><li>Children- cognitive development of low ses boys </li></ul><ul><li>Adolescents-higher cortisol levels </li></ul>
  72. 73. What Can Be Done? <ul><li>ROUTINE SCREENING </li></ul><ul><li>REFERRAL TO TREATMENT </li></ul>
  73. 74. Why Screen for Perinatal Depression? <ul><li>Screening is associated with increased detection </li></ul><ul><li>Georgiopoulos et al., 1999, 2001 </li></ul><ul><ul><li>EPDS screening resulted in increased chart-based diagnosis of PPD from 3.7% to 10.7% after one year of universal screening – Rochester, MN </li></ul></ul>
  74. 75. Barriers to Detection <ul><li>Women will present themselves as well as they are ashamed and embarrassed to admit that they are not feeling happy </li></ul><ul><li>Media images contribute to this phenomena </li></ul>
  75. 76. Barriers to Detection <ul><li>Women will present themselves as well as they are ashamed and embarrassed to admit that they are not feeling happy </li></ul><ul><ul><li>Tom Cruise: Snap out of it mentality </li></ul></ul><ul><li>Media images contribute to this phenomena </li></ul>
  76. 80. Barriers to Detection (cont) <ul><li>Lack of knowledge about range of postpartum disorders </li></ul><ul><li>They don’t want to be identified with Andrea Yeats </li></ul><ul><li>May genuinely feel better when you see them (they got dressed, out of house, lots of attention, not isolated) </li></ul>
  77. 81. “ I Was Depressed But Didn’t Know It.” <ul><li>Commonalities in the Experience of Non-depressed and Depressed Pregnant and Postpartum Women </li></ul><ul><li>Changes in appetite </li></ul><ul><li>Changes in weight </li></ul><ul><li>Sleep disruption/insomnia </li></ul><ul><li>Fatigue/low energy </li></ul><ul><li>Changes in libido </li></ul>
  78. 82. What is Required for Effective Screening? <ul><li>What to do with a positive screen? </li></ul><ul><ul><li>Implement or refer for diagnostic assessment </li></ul></ul><ul><li>Arrange for treatment </li></ul><ul><ul><li>Antidepressant medication </li></ul></ul><ul><ul><li>Psychotherapy (individual or group) </li></ul></ul><ul><li>Arrange for follow-up </li></ul>
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