Depressive Disorders and Bipolar and Related Disorders (Mood Disorders)
Variations in mood are common in everyday life. People normally feel sad when they experience a loss or disappointment and feel happy when they anticipate or experience a positive event. In contrast, patients with primary mood disorders show discordance between life events and how they feel emotionally. There may be no change in their current social circumstances to account for their emotions, or they may feel increased, decreased, or even contradictory emotional responsiveness to a change. For example, a student who does poorly on an exam remains so sad that 9 months later he has little appetite for food, has lost 20 lb (9.1 kg), and cannot enjoy his favorite activities. Another student who does well on an exam feels elated and believes she can mentally transmit her superior knowledge to others. The first student shows evidence of depression, and the second shows the elevated mood and psychotic thinking that can characterize mania. Two other abnormal mood states, dysthymia and hypomania, are attenuated versions of depression and mania, respectively.
 FIGURE 13-1. A diagnostic flowchart for a patient with a depressed mood after medical and pharmacological causes of the symptoms have been ruled out. |
It can be difficult to distinguish between normal variations in mood and mood disorders. Symptoms such as suicidality, severe weight loss, absence of pleasure in one’s usual activities (i.e., anhedonia) and extreme guilt (the SWAG symptoms, see below) as well as disruption in work or interpersonal relationships help identify the latter. In severe cases, psychotic symptoms such as delusions or hallucinations may also be present in a mood disorder patient.
The primary mood disorders include major depressive disorder (MDD) and bipolar disorder (I and II) and their less severe counterparts, persistent depressive disorder (dysthymic disorder) and cyclothymic disorder. The mood states of depression, mania, dysthymia, and hypomania individually or in combination characterize these disorders (Fig. 13-1). Mood symptoms that occur because of a medical condition or substance use (i.e., secondary mood disorders) are correctly diagnosed as mood disorders resulting from a general medical condition or substance-induced mood disorder.
table 13.1 DSM-5 DIAGNOSTIC CRITERIA FOR A MAJOR DEPRESSIVE EPISODE | ||||||||||||||||||||||||||||
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• MAJOR DEPRESSIVE DISORDER
MDD is identified by one episode or recurrent episodes of major depression in an individual’s lifetime. The DSM-5 diagnosis for a major depressive episode requires that at least five of nine listed symptoms (Table 13-1) be present most of the time for at least a 2-week period.
Characteristics
An episode of major depression characteristically involves not only unhappiness but also decreased interest and pleasure in one’s usual activities and decreased appetite for pleasurable stimuli such as sex and food. Lack of appetite for food often leads to significant (more than 5% of body weight) weight loss. Depressed patients also often have difficulty maintaining sleep (see Chapter 7) and become chronically fatigued. In atypical depression, patients are more likely to show weight gain rather than loss, and they are more likely to show excessive somnolence. Patients with atypical depression also typically report a feeling of heaviness in the arms and legs (leaden paralysis) and may also have a craving for carbohydrate-rich food.
Sometimes, depressed patients show confused thinking and mild memory problems. In the elderly, these cognitive symptoms may be misdiagnosed as dementia, that is, pseudodementia (see Chapters 4 and 18). Depressed patients also typically show diurnal variation in symptoms and feel more depressed in the morning and better in the evening.
Intense feelings of guilt and suicidal thoughts (ideation) and actions occur in depression. Suicide is a particular danger in depressed patients who feel hopeless, have been hospitalized for depression, or have psychotic symptoms, such as delusions (Bostwick & Pankratz, 2000) (see Chapter 14). If they occur, the delusions of depression commonly are congruent with the negative mood and involve themes of destruction, catastrophe, and fatal illness.
SWAG is a short mnemonic device that can be used to quickly identify depression and differentiate it from normal sadness. If one of the following symptoms is documented, it is most likely that the patient is depressed:
S—Suicidality (serious thoughts or attempts at self-destruction) or
W—Weight loss (more than 5% of normal body weight without medical cause) or
A—Anhedonia (loss of pleasure or interest in usually pleasurable activities) or
G—Guilt (feelings of responsibility for negative life events when little or none exists)
Masked depression and depression with seasonal pattern (seasonal affective disorder)
Physical symptoms, such as headaches and body aches, are common in depressed patients. Up to 50% of depressed patients seem unaware of or deny that they are depressed; instead they report vague physical symptoms. Patients with this masked depression tend to first seek help from primary care doctors (Green et al., 2000; Whooley & Simon, 2000). The diagnosis of masked depression is considered only when an identifiable organic cause for the physical symptoms is absent and when the patient has other symptoms of depression, such as weight loss and insomnia.
Depression with seasonal pattern, a specifier used with MDD, is associated with the seasons and short or long days. The short-day type of this disorder, which commonly presents with atypical symptoms, often can be treated effectively with fullspectrum light exposure used alone or along with antidepressants.
Etiology and occurrence
The causes of MDD can be biological or psychosocial, but MDD is usually caused by a combination of both factors. Biological factors include heredity, altered neurotransmitter activity, and abnormalities of the limbic-hypothalamic-pituitary-adrenal axis (see Chapter 5). The psychosocial etiology of depression includes the loss of a primary attachment figure, such as a parent in childhood, or the catastrophic loss of a loved one, such as a spouse or child, in adulthood. Other psychological factors that have been implicated in depression are low self-esteem and negative interpretations of ordinary life events. Some believe that the symptoms of depression result from feelings of helplessness caused by repeated futile attempts to escape negative life situations (i.e., the learned helplessness model of depression; see Chapter 9). Although there is little association between mood disorders and ethnicity, education, marital status, or income, being female is a significant risk factor for MDD. In the United States, the lifetime prevalence of this disorder, about 5% to 12% for men, is almost twice as high in women. Although the healthy elderly are not more likely to be depressed than younger people, older persons who are chronically ill or those who are widowed are at increased risk for depression (Byrne & Pachana, 2010).
Management
Depression can be treated successfully in most patients. However, only about 25% of depressed patients seek and receive treatment. As with medical illnesses, women are more likely than men to seek professional help.
Patients do not seek treatment for depression for several reasons. They may not realize that their physical symptoms are a result of depression (see Section “Masked depression and depression with seasonal pattern”). Even if patients know they are depressed, they may not be able to afford treatment. Health insurance plans may not fully cover the costs of treatment for emotional disorders such as depression. Also, many Americans consider being stoic and uncomplaining about illness a virtue, and illness itself a personal failure or even a moral weakness. These notions are intensified when the patient’s illness is emotional rather than physical, and thus less “real.”
Without treatment, most episodes of depression are self-limiting and last approximately 6 to 12 months. However, during the episode, the patient is at high risk for accidents, suicide, and social problems, such as job loss and marital difficulties. Most patients have repeated episodes of depression; some, particularly those with comorbid psychiatric disorders such as persistent depressive disorder (see later text) or substance-related disorder (see Chapter 23), remain chronically depressed.
Successfully treated episodes of depression last less than 3 months. The most commonly used and effective treatments are pharmacologic agents, including the heterocyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (see Chapter 19). Because of their more positive side-effect profiles, SSRIs such as fluoxetine (Prozac) and other newer antidepressants are now used as first-line agents (see Chapter 19). If a patient does not respond or does not respond completely to antidepressant therapy, augmenting strategies include adding lithium, thyroxine, or an atypical antipsychotic (see Chapter 19) to the antidepressant regimen. Because all antidepressants take at least 3 weeks to work, psychostimulants, which work more quickly, are used in certain depressed patients to treat depression. However, in contrast to antidepressants, stimulants can cause tolerance and dependence (see Chapter 23). Electroconvulsive therapy, in which a grand mal seizure is induced by passing an electric current across the brain (see Chapter 19), is a socially maligned but effective treatment for severe depression, particularly if it does not respond to antidepressant medications. This therapy is also used when antidepressants are too dangerous or have intolerable side effects, or when rapid resolution of symptoms is necessary because a patient is acutely suicidal or psychotic.
Psychological treatment for depression, including psychoanalytic, interpersonal, family, behavioral, and cognitive therapies, can be helpful
(see Chapter 11
(see Chapter 11
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