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  1. 1. Handbook of Disabilities Mood Disorders Mood Disorders Also called Affective Disorders, Depressive Disorders Description of the Disability Mood disorders are a disturbance of the emotions, which spills over into almost every other aspect of life. Mood disorders affect how people think, how they behave, how they care for themselves, and their overall health. In that sense, mood disorders are total body disorders. On the one hand, mood disorders are one of the easiest disabilities for others to relate to because most of us have experienced something like it. On the other hand, this makes it difficult for people to grasp how different the intensity of clinical depression is from the mild depression that most people occasionally experience. It becomes very easy to think the person with depression should just snap out of it or try to think about something else, but their situation is not that simple. Most people experiencing depression are profoundly more affected by their moods than the average person ever is. The depression most people experience is a mild, reactive and short-term depression – a response to some event or series of events in their life that disrupts their feelings, but only for a little while. This type of reactive depression responds well to psychotherapy, if needed, or to talking to a friend and waiting for the mood to pass. Clinical mood disorders are not reactive: although they may be triggered by an event or sequence of events, they are disproportionately intense, last for weeks or months at a time, and do not respond to talking and other simple fixes. Mood disorders leave individuals debilitated and unable to function in basic ways. Along with substance abuse, mood disorders are one of the most commonly coexisting disabilities. There are three basic types of mood disorders: Depression, Dysthymia, and Bipolar Disorder. Depression (Also called Clinical Depression, Major Depression) To be considered clinically depressed, the DSM IV requires that a person be depressed for at least 2 weeks with symptoms present nearly every day. The central features are feeling sad or down and not enjoying anything. The person also usually feels profoundly tired, even if they can’t sleep. They find the smallest tasks to be too much work, including things such as dressing, showering, and answering the phone. There is a large set of other secondary symptoms, including: Loss of self-esteem Withdrawal Feelings of helplessness or worthlessness This document is a product of RCEP7 and the Curators of the University of Missouri 1 Updated December 5, 2001
  2. 2. Handbook of Disabilities Mood Disorders Excessive or inappropriate guilt, sometimes almost delusional in scale Excessive crying Agitation (difficulty sitting still, pacing, hand wringing) Psychomotor retardation (slowed speech, thinking, movement; long pauses before responding; softened speech; minimal response to conversations) Sleep disturbance (usually insomnia, sometimes excessive sleep) Overwhelming sluggishness Persistent daytime sleepiness Difficulty concentrating, easily distracted Difficulty making decisions Change in eating habits, change in weight Abnormal thoughts about death Thoughts about suicide, plans to commit suicide, or suicide attempt(s) Reduced interest in daily activities It is important to note that, although suicide attempts are not very common, there is no way to predict whether someone with suicidal thoughts will or will not attempt suicide. Any indication of suicidal thoughts or plans should be passed along for attention by a therapist. No one knows what causes depression. There is a host of theories, but none is especially dominant. The cause is probably a combination of genetics, brain/body neurochemistry, personality type, patterns of thought, and other factors. Effective treatment usually addresses both psychological and medical approaches to understanding depression. In addition, effective treatment will take time. The individual has typically spent a lifetime learning or developing the disorder (depending on your perspective of the cause), and it takes time to alter how their emotional system is used to functioning. People experiencing depression usually have difficulty organizing things and making decisions. This can impact the rehabilitation and employment processes, so it is important for VR counselors understand this and not rush the individuals. Many VR counselors report that individuals with mood disorders ask the counselor to make the decisions for them. They may also have difficulty concentrating on instructions or options given to them, so counselors may need to repeat things or confirm through conversation that the person understands what the counselor has said. There are several possible patterns to the depressive episodes. Some individuals have only one episode in their life. Others have episodes many years apart or clusters of episodes with years between the clusters. Some individuals have a pattern of increasing frequency as they grow older. If left untreated, a major depressive episode can last between 6 months and one year. With treatment, most episodes end within three months. This document is a product of RCEP7 and the Curators of the University of Missouri 2 Updated December 5, 2001
  3. 3. Handbook of Disabilities Mood Disorders Children can also be clinically depressed, although their symptoms can be somewhat different. They may pretend to be sick, refuse to go to school, or show separation anxiety by clinging to a parent or worrying about what will happen if a parent dies. Older children may sulk, feel misunderstood, get into trouble at school, and act irritable. Unfortunately, each of these symptoms can also occur innocently as a phase of a normal childhood, making it difficult to know if the child is actually depressed. Usually only a parent or teacher can tell when a child is “not him self" and the difference is enough to suggest professional assessment. Incidence Statistics for Major Depression 18.8 million adult Americans experience a depressive disorder, including depression, dysthymia, and bipolar disorder each year 9.9 million adult American experience major depression each year Major depression is the leading cause of disability in the US, according to the Harvard School of Health Women experience depression about twice as often as men, but the reasons are not clear. There may be hormonal issues, role responsibility issues, or other causes. Men are more likely to hide their depression than women. Women are more likely to attempt suicide; men are 4 times more likely to succeed. The average age of onset/diagnosis is 40, and 50% of individuals experience the first depressive episode between the ages of 20 and 50. 50% of people experiencing a first depressive episode will have at least one more in their life. 25% of people experiencing a first depressive episode will have a second one within 6 months. 5%-10% of people experiencing a first depressive episode will later have at least one manic episode and which will most likely develop into recurring bipolar disorder (see below). 10% to 15% of individuals with major depression will still experience depressive episodes after 5 years of treatment. As the disorder progresses, the depressive episodes tend to occur more frequently and last longer. Dysthymia Dysthymia is milder than major depression, but the DSM IV requires that it have lasted for at least 2 years. Individuals with dysthymia are not as seriously debilitated as individuals with major depression, but they are functioning at a significantly reduced level. They often describe it as living in a constant cloud of gloom. In addition to sadness, the person may experience: Low self-esteem Feelings of helplessness or worthlessness This document is a product of RCEP7 and the Curators of the University of Missouri 3 Updated December 5, 2001
  4. 4. Handbook of Disabilities Mood Disorders Fatigue Sleep disturbance (usually insomnia, sometimes excessive sleep) Difficulty concentrating, easily distracted Difficulty making decisions Change in eating habits, change in weight Feelings of incompetence Reduced interest in pleasant activities Because the mood will have lasted for so long, the person may think of these symptoms as part of who they are and not see them as part of a disorder. In most cases, the disorder will have developed in childhood, adolescence, or young adulthood, contributing to this sense of it being a part of them. Alternatively, the symptoms may come and go, but always return within 2 months. For some individuals, the dysthymia is initially triggered by stressful life event such as the loss of a spouse, the birth of a child, or sudden unemployment. Incidence Statistics for Dysthymia 10.9 million adult Americans experience dysthymia during their life 40% of individuals with dysthymia also experience major depression or bipolar disorder in any given year. Women are 2 –3 times more likely to be diagnosed with dysthymia than men Bipolar Disorder (also called Manic Depression, Bipolar Affective Disorder, Bipolar I Disorder) Bipolar disorder involves an alternating sequence of depressive episodes and episodes of elation (or “mania”) lasting at least one week. Some people with bipolar disorder experience mostly depression with only a few manic episodes, others experience mostly mania with only a few depressive episodes, and others an equal balance. A manic episode can start over a period of days or even hours. In addition to the episodes of major depression, short (but intense) “mini-depressions” can occur during the manic episodes. This switch in mood during a manic episode can sometimes be dramatic, changing in just a few minutes, but usually it is more gradual. The intense mini- depressions can last hours or sometimes days, but they do not last for several weeks like major depressions do. Individuals who move quickly between the manic and depressive moods during a manic episode are sometimes called “rapid cyclers”. If both manic and depressive moods show up every day for at least a week, the episode is labeled “mixed”. In between major depressive episodes and manic episode, most individuals can function normally. However, some people with bipolar disorder continue to show unstable moods This document is a product of RCEP7 and the Curators of the University of Missouri 4 Updated December 5, 2001
  5. 5. Handbook of Disabilities Mood Disorders (“Lability of Affect”) and difficulty with social and work skills in between episodes. A few individuals experience psychotic symptoms in between episodes. The dominant moods of a manic episode are high-energy enthusiasm and confidence. The individual will seem to be a bundle of energy, excited about a dozen things at one time, and full of big plans and ideas. The DSM IV uses the term “expansive” to describe the overwhelming confidence of people experiencing a manic episode. They will have no doubt they can succeed at whatever they want, befriend or convince anyone they want, or acquire whatever money or things they want. They may go up to strangers in restaurants and confidently start a conversation, or call long lost friends early in the morning and try to sell them something. On the other hand, a few people will be irritable (but still energetic) rather than enthusiastic during manic episodes. In addition to this confidence, the person’s speech usually changes. They usually speak very quickly, change subject often, and are difficult to interrupt (“Pressured Speech”). They may also tell a lot of jokes or irrelevant stories. Sometimes their speech becomes theatrical, with dramatic gestures and bursts of song. They may start using words based on the sound of the words rather than the meaning of the words. Individuals who are more irritable than enthusiastic during a manic episode may launch into angry rants or make a lot of hostile comments. The person may make a lot of demands on people around them. They may have a lot of sexual ideas or plan romantic conquests. During a manic episode, the person may be very appealing and charismatic to people who do not know them. Friends and family, however, will notice the dramatic change from the person’s normal behavior. After the episode passes, the person may be very embarrassed about their behavior and its consequences. Symptoms of the manic phase include: Elevated mood Rapid mood shifts (“lability of affect”) Increased activity Flight of ideas or racing thoughts Inflated self-esteem Decreased need for sleep Agitation More talkative than usual or pressure to keep talking Agitation (difficulty sitting still, pacing, hand wringing) Change in eating habits, change in weight Poor temper control Excessively irresponsible behavior This document is a product of RCEP7 and the Curators of the University of Missouri 5 Updated December 5, 2001
  6. 6. Handbook of Disabilities Mood Disorders Increased goal-directed activities Excessive, but impaired, involvement in high risk, pleasurable activities Delusions Hallucinations Some people experience shorter, less intense manic episodes, which last less than a week and do not completely debilitate them. These are called Hypomanic Episodes, and individuals who experience them along with major depression are diagnosed with Bipolar II Disorder. However the symptom list for hypomanic episodes is the same as for manic episodes. Incidence Statistics for Bipolar Disorder Bipolar is less common than major depression. 2.3 million adult American experience bipolar disorder each year Equal number of men and women experience bipolar disorder Left untreated, a manic episode can last as long as three months Usually first presents as major depression Usually has earlier onset than major depression. Bipolar disorder can occur between childhood and age 50, but the mean age of onset/diagnosis is age 30. 10%-20% of individuals diagnosed with bipolar disorder primarily experience manic episodes. On average, the period between manic episodes is 6 to 9 months if untreated. This interval tends to decrease for a particular person over time. 1/3 of individuals diagnosed with bipolar disorder experience a significant decline in social skills and experience chronic symptoms. Common Treatments, Medications, and Side Effects Treatment of major depression and bipolar disorder is very difficult and usually involves a variety of approaches. As mentioned above, the exact causes of mood disorders are unknown, so successful treatment usually involves a combination of medication and psychotherapy. It is also important to note that employment can often help the treatment and control of mood disorders by providing some structure and sense of purpose in a person’s life. Medication There are many possible medications for depression and bipolar depression, with more appearing every year. Most of the time individuals with bipolar disorder require a combination of drugs to address different aspects of their situation. The physician and individual have to use a trial and error process to find the right combination of drugs and dosages. The process is further complicated by the fact that most of the drugs take several weeks to several months to reach effective levels in the person’s body. This document is a product of RCEP7 and the Curators of the University of Missouri 6 Updated December 5, 2001
  7. 7. Handbook of Disabilities Mood Disorders In addition, there can be side effects of the drugs that require further drug treatment. Whenever you begin significantly altering the balance of neurotransmitters and hormones in the body, there will be an unpredictable cascade of effects on regulatory functions of the body as well. The physician and individual must pay close attention to possible side effects during the trial and error process. Uncontrolled side effects can cause permanent damage and lead to secondary health conditions in some individuals with depression or bipolar depression. Fortunately, many of the newer drugs have significantly fewer side effects. Unfortunately, this decrease in side effects is accomplished with a specialization of the effects of the drug, reducing their general utility. This means that when they work for a person, they work well, but only for a few people, so the person may have to try many more such drugs to find the right fit. This is part of the reason drugs for mood disorders are some of the most expensive of all drugs. Because of these complications, the trial and error process for finding a combination of drugs to successfully control mood disorders can sometimes take years. It is important that the person is allowed this time, if possible, and not rushed into a job placement before they feel their mood is stable and under control. However, financial pressure may not allow that freedom. Even after stabilization, the person may experience occasionally crisis periods when they and their physician will need to adjust the medication. It is not productive to go into great detail here about the different neurotransmitters and the effects of different drugs related to depression and bipolar depression. The topic is very complex and the information changes rapidly. It is the job of the physician, not the VR counselor, to stay current on these topics. However, the VR counselor should know the basic types of drugs that may be involved. These include: Antidepressants • SSRI Antidepressants • Tricylic Antidepressants • MAO Inhibitor Antidepressants Mood Stabilizers • Lithium • Some antiseizure medications, including Tegretol and Depakote • Some antipsychotic medications, including risperidone and quetiapine (Seroquel) Antipsychotics (if psychosis is part of manic episodes) Sedatives (if insomnia is an issue) (see Drugs entry for side effects) This document is a product of RCEP7 and the Curators of the University of Missouri 7 Updated December 5, 2001
  8. 8. Handbook of Disabilities Mood Disorders In severe cases of depression that do not respond to medication, the physician may decide to use Electroconvulsive Therapy (ECT). ECT is essentially a way to trigger an artificial seizure in the person, since researchers have found that individuals with seizure disorders and depression often get relief from the depression after a seizure. This is probably due to a massive release of neurotransmitters into the brain, but no one knows for sure. Physicians deliver ECT in a hospital setting and in a carefully controlled way. The individual receives a mild anesthesia and muscle relaxant beforehand so they will experience little pain. The electrodes are carefully positioned to deliver the electric current in specific parts of the brain. The resulting seizure usually lasts between 20 and 90 seconds. The individual is usually awake again within 5 or 10 minutes. ECT treatment usually involves 6 to 10 sessions, with one given every two or three days. It must be emphasized that ECT is a very controversial treatment. Even through it increased in popularity in the last few decades, there are still many people who strongly disapprove of it. Advocates for the therapy say it works very well, providing relief for approximately 70% of people who receive it (and, remember, it is only used when other treatments have not worked). They say it has few side effects other than some short-term memory problems. Critics say it does not work well and it only helps around 30% of the individuals who receive it. They say there are significant side effects, including major memory problems and permanent brain injury. They also report that patients getting ECT are generally not told about the risks. The situation is further complicated by the lack of federal regulation over the administration of ECT. When ECT works, the person generally has a significant improvement in their mood within two weeks of the first treatment, but the results also usually fade after a few months. This may be enough to end the current depressive episode, but the person will need to take medication to prevent future episodes and may need more ECT treatments if depressive episodes return. As mentioned above, some individuals find ECT very helpful, with few side effects, while others find it does not help at all. In addition to ECT, Psychosurgery/neurosurgery is also sometimes used to treat severe depression that has resisted all other treatments. See the OCD entry for a description of psychosurgery treatment. Possible Functional Issues Fatigue Difficulty in making decisions Difficulty with self care (bathing, dressing, grooming, nutrition) Difficulty sitting still (psychomotor agitation) Impaired social skills Impaired judgment Difficulty coping with changes Inconsistent behavior This document is a product of RCEP7 and the Curators of the University of Missouri 8 Updated December 5, 2001
  9. 9. Handbook of Disabilities Mood Disorders Difficulty concentrating Low self esteem, difficulty advocating for themselves Difficulty sleeping or excessive sleeping (over-sleeping) Difficulty keeping on schedule Initial Interview Considerations Initial Questions How would they describe their mood? How would they describe the stability of their mood? What times of day are best for them, in terms of their mood and energy? What times of day are worst? What times of year are best or worst for them? Do they see seasonal cycles? What types of hobbies or activities do they do when they are feeling good? (gets at skills, interests) What sort of side effects, if any, do they experience from their medication? What sort of things do they do, beside medication, to help control their mood? What helps them manage their mood? How do they feel about the medication (if any)? Do they dislike it or have any strong feelings about it? How much trouble, if any, do they have remembering to take the medication? What symptoms do they experience during an episode? What symptoms do they experience, if any, in between episodes? How has their mood disorder affected their work? What symptoms have caused the most trouble at work? How well do they sleep? How often do they feel sleepy during the day? How is their stamina? How long can they do something before they feel too tired to continue? How do they feel about working in teams or groups? Do they think this would help their mood? Do they think it would be a challenge for them? Initial Observations Do they seem irritable? Some individuals with bipolar disorder may appear irritable rather than exuberant during their manic phases. How are their social skills? Some individuals show difficulty with social skills even in between episodes. This document is a product of RCEP7 and the Curators of the University of Missouri 9 Updated December 5, 2001
  10. 10. Handbook of Disabilities Mood Disorders Interview Accommodations (if any) Confirm, through conversation, that the person understands what has been said and what their options are. Repeat or rephrase things as often as necessary to help them. Give them time to make decisions or organize their thoughts. Resist any pressure from them to make the decisions for them. Write down, or encourage the person to write down, a summary of what was discussed and decided, plus what is planned for the future. If the person writes it down, review it with them to make sure it is complete. Possible Accommodations and Assistive Technology Flexible schedule, including options to deal with: • Sick days on short notice • Daily rhythms of medication and side effects (when are they at their best during day) • Seasonal cycles Supported employment Community-based assessment can be very useful for individuals with mood disorders An office with a sunny window or skylight (sunshine can help lift one’s mood) Job mentoring by a coworker Medication reminder devices Career Planning Issues If possible, do not try to place them in employment until their moods are stabilized through treatment. They may not have that flexibility. If possible, provide plenty of time and opportunities for the person to explore different employment possibilities. Keep their options open and realize that making firm decisions may be difficult for them. With the person’s permission, contact their physician to discuss their mood stability and their compliance with medication. Employment can often help the treatment and control of mood disorders by providing some structure and sense of purpose in their life. On the other hand, attempts to place them when they are not yet stabilized could lead to failures, making treatment more difficult. Periodicity of episodes may be predictable. With some research on medical records, you should be able to figure out what days of the month or months of the year they have the most trouble and adjust work schedules accordingly. This document is a product of RCEP7 and the Curators of the University of Missouri 10 Updated December 5, 2001
  11. 11. Handbook of Disabilities Mood Disorders Compliance with medication is of paramount importance. Because of possibly significant side effects, the VR counselor should stay alert to any signs the person is non-compliant or is self-medicating. Medical insurance issues to cover expensive medications, including SSA work incentives, should be addressed. Assess the need for reliable transportation. Cognitive skills, problem solving usually not affected (if stabilized) Dexterity, physical strength not affected Stamina may be an issue, depending on medications Support group or job club may be useful Emerging Issues New medications and their availability Acceptance by the community, including employers The tension between adherence to medication regime and individual choice Additional Information Resources National Depressive and Manic-Depressive Association (NDMDA): National Institute of Mental Health, depression publications: National Mental Health Association (NMHA): Focus On Depression, part of (a critical review of electroconvulsive therapy): This document is a product of RCEP7 and the Curators of the University of Missouri 11 Updated December 5, 2001