Chapter 7.  Powerpoint outline on Affective disorders

Slide 1.Time to think...

 How would you be able to tell the difference between normal sadness and depression?  Do you think itÕs reasonable for someone to expect to never be depressed?  Why (or why not)?

Slide 2. Some numbers...

• More than 46m Americans suffer from depression each year
• Approximately 1/3 (14m) suffer from chronic depression
• Adults 25 to 44 are hardest hit
• Women are diagnosed with depression about twice as often

Slide 3. Costs of depression...

• Loss of pleasure
• Costs US economy approximately $53b annually
• 32% of people with an affective disorder also abuse substances
• People with depression disproportionately use all medical services (Simon, VonKorff, & Barlow, 1995)
• People with depression: $4246/yr
• Controls: $2371/yr
• Cost of depression only accounted for 20% of the difference between the groups and continued after termination from treatment

Slide 4. Major depressive disorder, single episode (APA, Ô94)

A. Presence of a single Major Depressive Episode.
B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.  Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Slide 5. Major depressive episode (APA, 1994)

Five or more symptoms in a period of two weeks,
representing a change in functioning:

 (1) depressed mood
 (2) decreased interest or pleasure
 (3) weight loss or gain (without dieting)
 (4) insomnia or hypersomnia
 (5) psychomotor agitation or retardation
 (6) fatigue/loss of energy
 (7) feelings of worthlessness/inappropriate guilt
 (8) decreased ability to think and concentrate
 (9) recurrent suicidal ideation

Not the effects of a substance, medical condition.
Not only bereavement.

Slide 6.

• What is the difference between depression and normal sadness?
• When would it make sense to be depressed?
• Why might depression be difficult to see in yourself or someone else?

Slide 7.Time to think...

Slide 8. Bipolar disorder, single manic episode (APA, '94)

A. presence of only one Manic Episode and no past Major Depressive Episodes;
B. the manic episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder not otherwise specified.

Slide 9. Manic episode (APA, '94)

A.  A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 weekÉ.
B.  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:
      (1)  inflated self-esteem or grandiosity
      (2)  decreased need for sleep É.
      (3)  more talkative than usual or pressure to keep talking
      (4)  flight of ideas or subjective experience that thoughts are racing
      (5)  distractibility (i.e., attention too easily drawn to unimportant or  irrelevant external stimuli)
      (6)  increase in goal-directed activity (either socially, at work or  school, or sexually) or psychomotor agitation
      (7)  excessive involvement in pleasurable activities that have a high  potential for painful consequences (e.g., engaging in   unrestrained buying sprees, sexual indiscretions, or foolish  business investments)
C.  The symptoms do not meet criteria for a Mixed Episode.
D.  The mood disturbance is sufficiently severe to cause 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.
E.  The symptoms are 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).

Slide 10. (Graphs of course of disorder)

Major depression

single episode Major depression

recurrent Dysthymia

Bipolar disorder

Slide 11. Hypomania

• Restlessness
• Fast thoughts, ideas flowing
• High energy
• Desire to do something
• May be accompanied by uncharacteristic flirting or spending

Slide 12. Frequency of affective symptoms

Slide 13. Genogram for Tennysons (Jamison, 1995) (high frequency of depression and bipolar disorder)

Slide 14. Comorbidities

Increased risk of suicide

55% have drug or alcohol problems

Perhaps increased creativity??? (Goodwin & Jamison, 1990)

Slide 15. Productivity of Schumann across lifespan (Goodwin & Jamison, 1990)

Slide 16. An insider's view of bipolar disorder (Jamison, 1993)

Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. The illness encompasses the extremes of human experience. Thinking can range from florid psychosis, or "madness," to patterns of unusually clear, fast and creative associations, to retardation so profound that no meaningful mental activity can occur. Behavior can be frenzied, expansive, bizarre, and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swing erratically between euphoria and despair or irritability and desperation. The rapid oscillations and combinations of such extremes result in an intricately textured clinical picture. Manic patients, for example, are depressed and irritable as often as they are euphoric; the highs associated with mania are generally only pleasant and productive during the
earlier, milder stages. (pp. 47-48)

Slide 17. Dysthymic disorder (APA, 1994)

(A) depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others (2 yrs.+); Mood can be irritable and 1 yr.+ in children;
(B) presence, while depressed, of 2+: (1) poor appetite or overeating; (2) insomnia or hypersomnia; (3) low energy or fatigue; (4) low self-esteem; (5) poor concentration or difficulty making decisions; (6) feelings of hopelessness;
(C) during the 2 yr. period (1 yr. for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A or B for more than 2 mo. at a time;
(D) no Major Depressive Episode has been present during the first 2 yrs. of the disturbance (1 yr. for children and adolescents); i.e. the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, in Partial Remission;
(E) there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder;
(F) the disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder;
(G) the symptoms are not due to the direct physiological effects of a substance or a general medical condition;
(H) the symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
Frequency of affective disorders

 Slide 18. Time to think...

People are often relieved when they find out that they have a "chemical imbalance" that makes them depressed or manic.  Why do you think this is?  What implications does this have for therapy?

 Slide 19. Somatic therapies

For depression (affecting norepinephrine or
serotonin?)
• Tricyclics
• MAO Inhibitors
• Selective Serotonergic Reuptake Inhibitors (SSRIs)
• ECT (cause of effectiveness is unknown)
For bipolar disorder
• Lithium

 Slide 20. (relationships among neurotransmitters)

   I. Neurotransmitters.

 A.     Monoamines

1. Catecholamines
    a.    Norepinephrine
    b.    Epinephrine
    c.    Dopamine
2.   Indoleamines
    a.    Serotonin

B.    Others

1. Ach, GABA, etc.

 Slide 21. Figure 07.03

 Slide 22. Agonists can...

1. Serve as precursor to NT
2. Increase release of NT
3. Prevent breakdown of NT in synapse
4. Stimulate post-synaptic receptors
5. Prevent re-uptake of NT

 Slide 23. Antagonists can...

1. Prevent the formation of NT from precursors
2. Make synaptic vesicles leaky
3. Prevent release of NT
4. Increase breakdown of NT in synapse
5. Block post-synaptic receptors

 Slide 24. No magic bullet!

 Slide 25. Tricyclics

• Tofranil, Pamelor, Elavil
• effective for about 50%, 65-70% if exclude dropouts
• Take several weeks to work
• regulate levels of NE
• Side effects:
• dry mouth, constipation, drowsiness, weight gain (Mn=13 lbs), blurred vision
•  many side effects disappear
• possibility of overdose

 Slide 25. MAOIs

• Nardil, Parnate
• Effective in roughly 55%, w/ fewer side effects
• Block breakdown of NE and serotonin
• Side effects:
• Consumption of a variety of foods (bananas, beer, some cheese, sausage, yeast, wine) can cause severe hypertension or death

 Slide 25. SSRIs

• Prozac, Zoloft, Paxil, Anafranil, Wellbutrin, Desyryl
• Efficacy similar to other drugs
• Regulate levels of serotonin
• Side effects:
• Agitation, insomnia, GI upset, lack of sexual desire
• More difficult to overdose

 Slide 26. Efficacy of Antidepressants (Depression Guideline Panel, 1993)

Slide 27. Relapse after treatment for depression (after Evans et al., 1992)

Slide 28. Lithium

• Effective therapy for bipolar disorder
• 30-60% VG response
• 30-50% some response
• 10 - 20% have poor response
• Long-term maintenance is recommended.
• No magic bullet.  Most medications have side effects
• Side effects:
• Significant weight gain
• Must monitor for drug toxicity and thyroid problems

 Slide 29. Time to think...

Think about a time when you were feeling distressed.  What were you thinking?  Do you think your thoughts were rational or irrational?  Why?

 Slide 30. ABCs of cognitive therapy

Activating Event   ->   Emotional  Consequences??

or

Slide 31. Common themes of irrational beliefs

Love

• If I am not liked by all others, that is terrible and I am no good.

Achievement

• If I don't consistently do a perfect job, I'm no good.

(Goldfried, 1988)

Slide 32. Cognitive triad

Negative cognitions around the following:

• Self
• Current events
• Future

Slide 33. Common thought errors

• Catastrophizing
• Minimizing
• Internalizing
• Stabilizing
• Globalizing

Slide 34. Optimists and Pessimists

Personalization

O: internal for good events, external for bad
P: external for good events, internal for bad

Pervasiveness

O: global explanations for good events, specific for bad
P: specific for good events, global for bad

Persistence

O: expect good things to continue, expect bad things are temporary
P: expect good things are temporary, bad things will continue

Slide 35. Goals of cognitive therapy

1. Actively become aware of your thoughts
2. Become aware of how they are maladaptive and how these may lead to emotions
3. Substitute accurate for inaccurate judgments
4. Gather feedback to determine whether these changes are correct

Slide 36. Goals for treatment of depression

Stop depression

Antidepressants may do this faster than cognitive therapy, but generally after about 3 weeks

Somatic therapies (antidepressants and ECT) are palliative treatments

Prevent recurrence of depression

• Cognitive therapy is much more successful at preventing relapses
• Cognitive and interpersonal therapies are curative???

Slide 37. Time to think...

If a family member wanted to commit suicide, what (if any) conditions would lead you to support his or her wishes?
 

Slide 38. Some numbers...

• More than 30,000 Americans complete suicide each year (1 every 20 minutes)
• 400,000 uncompleted attempts per year
• Perhaps 80% of these are related to an affective disorder
• Suicide rate for 15-24 year olds has tripled since 1950
• Impulsive, aggressive, antisocial behavior aggravated by drug abuse
• Common methods:
• handguns, drug overdose, cutting/stabbing, jumping, inhalation, hanging, drowning (in order of frequency)
1999 NY Times Almanac

Slide 39. Deaths in U.S. males, 35 or younger (Jamison, 1999)

Slide 40. Leading causes of death in US per 100,000

1. Heart diseases (276)
2. Cancer (205.2)
3. Cerebrovascular disease (60.5)
4. Pulmonary diseases (40.0)
5. Accidents (35.4)
6. Pneumonia and influenza (35.4)
7. Diabetes mellitus (23.2)
8. AIDS (12.3)
9. Suicide (11.6)
10. Liver disease and cirrhosis (9.5)
US Dept. of Health & Human Services,

National Center for Health Statistics, 1997

Slide 38. Leading causes of death for men and women (15-44), worldwide (Jamison, 1999)

Women
1. Tuberculosis (9.4%)
2. Suicide (7.4%)
3. War (4.4%)
4. Maternal hemorrhage (4.0%)
5. Traffic accidents (3.7%)
6. HIV/AIDS (3.4%)
7. Cerebrovascular disease (2.7%)
8. Ischemic heart disease (2.7%)

Men
1. Traffic accidents (10.9%)
2. Tuberculosis (9.0%)
3. Violence (8.8%)
4. Suicide (6.6%)
5. War (5.0%)
6. Ischemic heart disease (3.7%)
7. HIV/AIDS (2.9%)
8. Cirrhosis of liver (2.9%)

Slide 39. Cultural and gender differences in suicide (Moscicki, 1995)

Slide 40. Race and age differences in suicide (Buda & Tsuang, 1990)

Slide 41. Predictors of completed suicide

• high lethality of plan
• behavior indicative of finalized decision to die
• presence of a specific plan
• availability of lethal means
• ending formerly meaningful relationships without substituting new ones
• severe depression,
• chronic alcoholism or drug addiction
• presence of psychosis, esp. if auditory hallucinations command particular acts
• prior suicide attempts, esp. a recent one
• family history of suicide
• improvement from a psychotic episode, but continuance of secondary depression
• advancing age, personal loss, physical illness (esp. chronic illness)
• single or divorced
• aged 15 -  24
• absence of a close and effective relationship with therapist
• mental incompetence preventing effective therapeutic relationship

(Simon, 1992, p. 259)

Slide 42. Ways that the media glamorizes and can promote suicide contagion

• Presenting simplistic explanations for suicide
• Engaging in repetitive, ongoing or excessive reporting of suicide in the news
• Providing sensational coverage of suicide
• Reporting "how-to" descriptions of suicide
• Presenting suicide as a tool for accomplishing certain ends
• Glorifying suicide or persons who commit suicide
• Focusing only on the suicide completer's positive characteristics  rather than also the problems that they were experiencing

Centers for Disease Control & Prevention, 1994

Slide 43. When a friend is suicidal

• Take your friend or family member seriously.
• Donít promise confidentiality.
• Involve other people.
• Contact MH professionals working with the person.
• Listen attentively.
• Express your concern.
• Ask direct questions about suicidal intentions.
• Acknowledge the personís feelings.
• Reassure them that things will become better.  Suicide is a permanent solution to a temporary problem.
• If possible, donít leave the person alone until the person is safe.


     guidelines from the National Depressive
     and Manic Depressive Association (1996)

Last modified October 15, 2001