CHAPTER 9: MOOD DISORDERS Bipolar disorder: once known as manic-depression.

ssion. Disorder marked by cycles between manic episodes and depressive episodes. One of the major mood disorders Mania: great energy and enthusiasm for everything, fizzling over with ideas, talking and thinking so fast that others cant keep up, impulsive actions Depression: energy and enthusiasm gone; slow to think, talk and move; joy drained from life Unipolar depression: experience only depression, without mania Suicide is very serious problem associated with mood disorders Symptoms of Depression: takes over whole person- emotions, bodily functions, behaviours, and thoughts o Emotional Symptoms: sadness; deep, unrelenting pain Anhedonia: lost interest in everything in life o Physiological and Behavioural Symptoms: changes in appetite, sleep and activity levels Lose appetite/eat more (binge eating) Sleep all day/difficulty sleeping Early morning wakening: form of insomnia; awaken at 3-4 a.m. and cant go back to sleep Psychomotor retardation: behaviourally slowed down; walk and gesture slowly; talk slowly and quietly (more accidents because they cant react quickly) Lack energy; chronically fatigued Psychomotor agitation: feel physically agitated; cant sit still, fidget aimlessly o Cognitive Symptoms Thoughts filled with themes of worthlessness, guilt, hopelessness and suicide Trouble concentrating and making decisions Delusions: beliefs with no basis in reality Hallucinations: seeing, hearing, or feeling things that arent real Delusions and hallucinations usually depressing and negative in context

Diagnosis of Unipolar Depressive Disorders DSM-IV-TR has 2 categories of unipolar depression: major depression and dysthymic disorder Diagnosis of major depression requires person experience either depressed mood or anhedonia, plus at least 4 other symptoms of depression chronically for at least 2 weeks and they interfere with ability to function Dysthymic disorder: less severe than major depression but more chronic. Diagnosis requires anhedonia or sad mood plus 2 other symptoms of depression for at least 2 years, during which symptoms dont remit for longer than 2 months Double depression: disorder involving cycle between major depression and dysthymic disorder. Even more debilitated than major depression or dysthymia alone and less likely to respond to treatments Most common disorders to co-occur with depression are substance abuse, anxiety disorders and eating disorders. Sometimes depression precedes and perhaps causes the other disorders and in other cases depression follows and ma be consequence of the other disorder DSM-IV-TR recognizes subtypes of major depression with the depressive phase of bipolar disorder o Depression with melancholic features: physiological symptoms of depression are prominent (ex. anorexia, early morning awakening, etc.) o Depression with psychotic features: depressing delusions or hallucinaitons o Depression with catatonic features: strange behaviours known as catatonia, which can range from complete lack of movement to excited agitation o Depression with atypical features: assortment of symptoms like positive mood, weight gain, etc. o Depression with postpartum onset: major depressive episode within 4 weeks of delivery Rarely develop mania postpartum, given diagnosis of bipolar disorder with postpartum onset

Postpartum blues: emotional liability (unstable and quickly shifting moods), frequent crying, irritability and fatigue- in the first few weeks after giving birth Depression with seasonal pattern: sometimes referred as seasonal affective disorder (SAD) People with SAD had at least 2 years of major depressive episodes and fully recovering from them. Symptoms tied to number of daylight hours in a day. Depressed when daylight hours are short and recover when daylight hours are long To be diagnosed with SAD mood changes cant be result of psychosocial events, they must seem to come on without reason/cause Some develop mania or have manic episodes during summer and diagnosed with bipolar disorder with seasonal pattern

Prevalence and Course of Depression Most common psychological problem and #1 source of disability in Canadian workforce Low rate of depression among older adults. Diagnosis of depression in older adults is complicated because: o Less willing to report symptoms because they grew up in less accepting society o Depressive symptoms often occur in context of serious medical illness o Older people more likely to have cognitive impairment so its harder to distinguish Some researchers suggest low rate is valid because: o Depression interferes with physical health so people with depression more likely to die before old age o As people age they develop more adaptive coping skills Depression rates high among young adults (15-24) Depression is costly to individual and society Once people get treatment they tend to recover quickly and risk for relapse is reduced but many depressed people dont seek care or wait years after symptoms start because they feel the symptoms are a phase theyre going through thatll pass with time or they dont have money to pay for care People with previous major depressive episodes tend to have enduring problems in many areas of their lives

Depression in Childhood and Adolescence Depression less common in children Highest rate among American Indians Youth using substances more likely to be depressed Depression may leave psychological and social scars if it occurs initially during childhood and adolescence Self-concept is still being developed and having depressive symptoms during this time can have long-lasting effects on content of their self-concept and if it interferes with learning it can have long-lasting effects on childs achievement Forming a negative self-view early in life can establish longstanding vulnerability for developing depression across the lifespan Depression may increase negative thinking because it brings with it a host of new negative events. Stressgeneration models suggest symptoms of depression can interfere with yougsters functioning in all domains of their lives and lead to increase in man-view early in life can establish longstanding vulnerability for developing depression across the lifespan Depression may increase negative thinking because it brings with it a host of new negative events. Stressgeneration models suggest symptoms of depression can interfere with yougsters functioning in all domains of their lives and lead to increase in man kinds of stressors (ex. paying for childs treatment may lead to family financial strain) Girls rates of depression escalate during puberty because grils dislike the physical changes with puberty (ex. weight gain) more than boys (increase in muscle mass). This has occurred more in European American girls not African-American and Latino girls because they dont accept pressure to be thin as much as European-Americans

BIPOLAR MOOD DISORDERS Symptoms of Mania: elated moods with irritation and agitation, grandiose self-esteem (view of self is unrealistically positive and inflated), thoughts and impulses race through mind, speak rapidly and forcefully, impulsive behaviours, grand plans and goals Diagnosis of Mania Diagnosis requires an elevated, expansive, or irritable mood for at least 1 week plus at least 3 other symptoms listed; plus they must interfere with ability to function: o Elevated, expansive, or irritable mood o Inflated self-esteem or grandiosity o Decreased need for sleep o More talkative than usual, pressure to keep talking o Flight of ideas/sense that your thoughts are racing o Distractibility o Increase in activity directed at achieving goals o Excessive involvement in potentially dangerous activities Bipolar I Disorder: o Major depressive episodes can occur but arent necessary for diagnosis o Episodes meeting full criteria for mania are necessary for diagnosis o Hypomanic episodes can occur between episodes of severe mania or major depression but arent necessary for diagnosis Bipolar II Disorder: o Major depressive episodes and hypomanic episodes are necessary for diagnosis o Episodes meeting full criteria for mania cant be present for diagnosis Hypomania: milder episodes of mania; has same symptoms as mania but difference is thathas same symptoms as mania but difference is that the dont interfere with functioning and dont involve delusions or hallucinations Cyclothymic disorder: milder but more chronic form of biplar disorder that consists of alteration between hypomanic episodes and mild depressive episodes over at least 2 years Rapid cycling bipolar disorder: person has 4 or more cycles of mania and depression within a single year

Prevalence and Course of Bipolar Disorder Bipolar disorder is less common than unipolar depression Bipolar disorder equally prevalent in men and women, most develop it in late adolescence or early adulthood Often face chronic problems on the job and in relationships between episodes Presence of symptoms associated with deficits in both social and occupational functioning and the symptoms appear to increase risk for relapse Often abuse substances which also impairs control over disorder, willingness to take medications, and functioning in life Controversial research issue on bipolar disorders is extent to which it exists and can be reliably diagnosed in children and young adolescents Some evidence suggests that people with bipolar disorder are more creative

BIOLOGICAL THEORIES OF MOOD DISORDERS Most biological theories of the causes of mood disorders focus on genetic abnormalitiesor dysfunctions in certain neurobiological systems. These 2 types of theories compliment each other: genetic abnormalities may cause mood disorders by altering persons neurobiology

The Role of Genetics

Family History Studies o Risk is higher for people with a bipolar relative, but only minority of them develop bipolar disorder o Unipolar depression clearly runs in families Twin Studies o Risk for bipolar disorder highest in monozygotic (identical) twins and decreases as genetic similarity between an individual and relative with bipolar disorder decreases Specific Genetic Abnormalities o Abnormalities on serotonin transporter gene may be involved in vulnerability to depression o Many researchers believe genetic predisposition to mood disorders is multifactorial- it involves many factors. Particular configuration of several disordered genes necessary to create mood disorder

Neurotransmitter Dysregulation Neurotransmitters: facilitate transmission of impulses across synapses between neurons Neurotransmitters that have been implicated in mood disorders are monoamines- specifically norepinephrine, serotonin and dopamine These monoamines found in limbic system- part of brain regulating sleep, appetite and emotional processes Monoamine theories: o Early theory was that depression was caused by reduction in amount of norepinephrine or serotonin in synapses between neurons. This was caused by increased degradation of NT by enzymes, or impaired release or reuptake of the neurotransmitter o Mania thought to be caused by excess of monoamines or dysregulation of levels of these amines, especially dopamine Recent studies focused on number and functioning of receptors for monoamines on neurons in people suffering from mood disorders In major depression, receptors for serotonin and norepinephrine appear to be too few or insensitive. In bipolar disorder its likely receptors undergo poorly timed changes in sensitivity that are correlated with mood changes Most neurotransmitter abnormalities found with mood disorders are state-dependent, differences present when mood disorders present but tend to disappear when mood disorders subsides

Brain Abnormalities Brain areas that may be involved in mood disorders: a) Prefrontal cortex b) Hippocampus c) Anterior cingulate cortex d) Amygdala Reductions in metabolic activity and reduction in volume of grey matter in prefrontal cortex, particularly left side, have been found in people with serious depression or bipolar disorder. Suggested that left prefrontal cortex more involved in approach-related goals and inactivity of this region is associated with lack of motivation and goal orientation in depression. Successful treatment of depression with antidepressant medications associated with increases in metabolic activity in left prefrontal cortex Anterior cingulate important in bodys response to stress, emotional expression, social behaviour and processing of difficult information People with depression show decreased activity in the anterior cingulate relative to controls, this may be associated with problems in attention, planning appropriate responses, coping and anhedonia found in depression Hippocampus critical in memory and fear-related learning. MRIs show smaller volume in hippocampus with major depression or bipolar disorder. PETs show lower metabolic activity in hippocampus with major depression

Damage to hippocampus could be result of chronic arousal of bodys stress response. People with depression show chronically high levels of cortisol, their bodies overreact to stress and dont return to normal levels as quickly. Hippocampus contains many receptors for cortisol and chronically elevated levels of cortisol may inhibit development of new neurons in hippocampus Amygdala helps redirect attention to stimuli that are emotionally salient and have major significance for individual. Studies of people with mood disorders show enlargement of amygdala and increased activity (which decreases normal values in people successfully treated for depression) Effects of overactivity in amygdala suggest it may bias people toward aversive or emotionally arousing information and lead to rumination over negative memories and negative aspects of environments Not known whether abnormalities in structure or functioning of brain are causes or consequences of mood disorders For some, initial cause may have been environmental but disorder may cause changes in brain that increase vulnerability to future episodes. For others brain dysfunction may be caused by abnormal genes

Neuroendocrine Factors Neuroendocrine system regulates number of important hormones, which affect basic functions such as sleep, appetite, sexual drive and ability to experience pleasure and also help body respond to environmental stressors 3 key components of neuroendocrine system- hypothalamus, pituitary and adrenal cortex- work together in biological feedback system that is interconnected with limbic system and cerebral cortex called hypothalamicpituitary-adrenal axis or HPA axis When confronted with stressor HPA axis become more active, increases bodys levels of major stress hormones such as cortisol, which helps body respond to stressor by making it possible to fight or flee from it. Once stressor is gone, HPA axis returns to baseline People with depression show chronic hyperactivity in HPA axis and inability to return to normal functioning following a stressor. Excess hormones produced by heightened HPA activity seem to have inhibiting effect on receptors for monoamines One model for development of depression is people exposed to chronic stress ma develop poorly regulated neuroendocrine systems. When exposed even to minor stress later in life, HPA axis overreacts and doesnt easily return to baseline. Overreaction creates change in functioning of monoamine NTs in the brain and an episode of depression is likely to ensue Womens Hormonal Cycles as a Factor o Many argue womens greater vulnerability to depression is tied to hormones- specifically, estrogen and progesterone o Evidence that women more prone to depression during premenstrual part of menstrual cycle, postpartum period and menopause. These are times when estrogen and progesterone levels change dramatically o Research shown most women dont experience significant changes in moods during times of hormonal change. However small group frequently experience increases in depressive symptoms during premenstrual phase. Many also have history of frequent major depressive episodes or anxiety disorders with no connection to menstrual cycle or other psychological disorders. This suggests they have general vulnerability to depression or anxiety rather than specific vulnerability to premenstrual depression o Researchers argue depression during premenstrual period should not be given diagnosis such as premenstrual dysphoric disorder rather be considered only exacerbation of major depression or dysthymia o Others argue premenstrual depression should be recognized separately because its different from depression that has not link with menstrual cycle o Something about menstrual cycle worsens mood in women with PMS, appears neither estrogen nor progesterone have consistent, direct effects on mood

Women who do become seriously depressed during postpartum period it doesnt seem linked to any specific imbalances in hormones o Given absence of biological changes noted in women experiencing postpartum depression and clear role of stressors in activating depressive episode, postpartum depression is best conceptualized as adjustment disorder o Postpartum depression often linked to severe stress in womens lives and women who have history of depression clearly at increased risk for postpartum depression. They may carry general vulnerability to depression triggered by physiological or environmental changes of postpartum period o About 1/10 women experience postpartum depression o Menopause marks cessation of periods and circulating ovarian hormones decrease dramatically o Evidence that womens moods are tied to hormones is mixed. Some clearly experience more depression during postpartum, menopause and other times when hormone levels change rapidly Increasing evidence that early traumatic stress or other serious, chronic stress, can lead to some of the neurobiological abnormalities that may predispose people to depression

PSYCHOLOGICAL THEORIES OF MOOD DISORDERS Diathesis-stress model of bipolar disorder in which diathesis (vulnerability) is a biological one (ex. genetic predisposition) and stressors can trigger new episodes

Behavioural Theories According to Lewinsohn and Gotlib, behavioural theory of depression suggests life stress leads to depression because it reduces positive reinforcers in a persons life. life stress tends to be more predictive of initial depressive episodes as opposed to later, recurrent episodes Person begins to withdraw, resulting in further reduction in reinforcers leading to more withdrawal and a selfperpetuating chain is created Lewinsohn suggests such a pattern is especially likely in people with poor social skills because more likely to experience rejection by others and withdraw in response rather than finding ways to overcome rejection Once person begins engaging in depressive behaviours, these behaviours are reinforced by sympathy and attention they engender in others Learned Helplessness Theory o Learned helplessness theory: type of stressful event most likely to lad to depression is uncontrollable negative events which lead people to believe theyre helpless to control outcomes in their environment o Belief in helplessness lead to losing motivation, reduce actions that might control the environment and unable to learn how to control controllable situations o Learned helplessness deficits: symptoms like low motivation, passivity, indecisiveness and inability to control outcomes from exposure to uncontrollable events o Studies on dogs showed dogs in uncontrollable shock group learned they were helpless to control the shock and passivity and inability to learn to control shock were result of learned helplessness o Helplessness depressions: when people believe they are helpless to control important outcomes in their environment

Cognitive Theories Aaron Becks Theory o People with depression look at world through negative cognitive triad: negative views of self, world and future o They then commit many types of errors in thinking that support their negative cognitive triad o Often negative thoughts so automatic that people with depression dont realize how they are interpreting situations

Becks theory led to most widely used and successful therapies for depression: cognitive-behavioural therapy o Errors in Thinking in Depression: All-or-nothing thinking: black-and-white, either perfect or failure Overgeneralization: see single negative event as never-ending pattern or defeat Mental filter: pick out single negative detail and dwell on it so vision of all reality becomes darkened Disqualifying the positive: reject positive experiences so you can maintain negative belief thats contradicted by everyday experiences Jumping to conclusions: make negative interpretation despite lack of facts Mind reading- conclude somebodys reactive negatively to you without checking this out Fortune teller error- anticipate bad outcome convincing self its an established fact Magnification (catastrophizing) or minimization (binocular trick): exaggerate importance of things or inappropriately shrink things until they appear tiny Emotional reasoning: assume negative emotions reflect way things are (ex. I feel it so it must be true) Should statements: try to motivate self with should and shouldnts, emotional consequence is guilt Labelling and mislabelling: extreme form of overgeneralization, instead of describing yours/somebodys error you attach a negative label (ex. Im/theyre a loser) Personalization: see yourself as cause of negative external event that youre not responsible for Reformulated Learned Helplessness Theory: focuses on causal attribution (explanation of why an event happened), people who habitually explain negative events by causes that are internal, stable and global blame themselves for these negative events, expect negative events to recur in future and expect to experience negative events in many areas of life o These expectations lead to long-term learned helplessness deficits plus self-esteem loss o Internal-stable-global attributional style for negative events puts people at risk for depression o Depressive realism: when asked to make judgments about how much control they have over situations that are uncontrollable, people with depression are quite accurate o Non-depressed people have illusion that they can control situations that are out of their control and have superior skills Ruminative Response Styles Theory: focuses on process rather than content of thinking as a contributor to depression. Tendencies to focus on symptoms of distress and possible causes and consequences of these symptoms, in passive and repetitive manner, leads to depression o Rumination: focusing on personal concerns and feelings of distress repetitively and passively o Rumination not just another symptom of depression, people with depression differ in extent to which they ruminate, those who ruminate more become more severely depressed over time and remain depressed longer o Women more likely to ruminate when depressed

Psychodynamic Theories Depressed people unconsciously punishing themselves because they feel abandoned by another person but cannor punish that person; dependency and perfectionism are risk factors fro depression Patterns of unhealthy relationships stem from peoples childhood experiences that prevented them from developing a strong and positive sense of self reasonably independent of others evaluations. As adults theyre constantly searching for approval and security in relationships with others. theyre anxious about abandonment and separation, may allow others to take advantage/abuse them, constantly striving to be perfect but dont feel secure or positive about themselves

Eventually problem in close relationship or failure to achieve perfection occurs and they plunge into depression Freud pointed out people who are depressed have many of the symptoms of people grieving death of loved one: feel sad, alone, unmotivated, and lethargic. Unlike grieving people they display severe self-hate and self-blame Freuds introjected hostility theory: people with depression, being too frightened to express rage for their rejection outwardly, turn their anger inward on parts of their own egos; their self-blame and punishment intended for others who have abandoned them

Interpersonal Theories Interpersonal theories of depression: view causes of depression as rooted in interpersonal relationships. Disturbances in peoples roles in relationships are thought to be main source of depression These disturbances may be recent (ex. finding out about husbands affair), others are rooted in long-standing patterns of interactions the people with depression typically have with important others Children who dont experience caregivers as reliable, responsive and warm develop an insecure attachment to caregivers which sets stage for future relationships Contingencies of self-worth: if-then rules concerning self-worth, such as Im nothing if a person I care about doesnt love me. children with insecure attachments develop these dysfunctional beliefs. Failures to meet these contingencies make them plunge into depression People who are so insecure in their relationships with others engage in excessive reassurance seeking: constantly looking for assurances from others that theyre accepted and loved. They never quite believe affirmations but keep going back for more. This might annoy family/friends slowly making the persons social support withdraw leading to more depression Theories suggest women base most of their self-worth on relationships and this makes them more prone to depression Jack & Helgeson argue females feel more responsible for relationship leading to less power and benefit in relationship

SOCIAL PERSPECTIVES ON MOOD DISORDERS Cohort Effect in Depression Cohort effect: people born in one period are at different risk for a disorder than people born in another period Proponents of cohort explanation suggest more recent generations are more at risk for depression because of rapid changes in social values that began in 1960s and disintegration of family unit Younger generation might have too high expectations for selves than older generations and they might have decrease in social support and common social values putting them at higher risk for depression

Social Status People who have lower status in society generally tend to show more depression (ex. Hispanics, Aboriginals, new immigrants) Womens lower social status puts them at high risk for physical and sexual abuse and these experiences often lead to depression Some of the differences between rates of depression may be tied to higher rates of abuse of women

Cross-Cultural Differences Prevalence of major depression lower among less industrialized and less modern countries. Probably because modern societies have fast-paced lifestyles and lack of stable social support and community values whereas less modern ones have community- and family-oriented lifestyles Some suggest people in less modern cultures may manifest depression with physical complaints

Ex. refugees in Somalia have concept similar to sadness called murug which arises when individual loses a loved one or another major negative life event occurs. Murug has symptoms- headaches and social withdrawal China, people facing severe stress often complain of neurasthenia, a collection of physical symptoms

MOOD DISORDERS TREATMENTS Biological Treatments for Mood Disorders Drug Treatments for Depression o Tricyclic antidepressants: help reduce symptoms of depression by preventing reuptake of norephinephrine and serotonin in synapses or by changing responsiveness of receptors for these neurotransmitters [imipramine, amitriptyline, and desipramine] Side effects: dry mouth, excessive perspiration, blurry vision, constipation, urinary retention and sexual dysfunction Can take 4-8 weeks to show an effect Can be fatal in overdose, wary prescribing to depressed who are suicidal o Monoamine Oxidase Inhibitors (MAOIs): decrease action of MAO enzyme, increasing levels of NTs in synapse o MAOIs can interact with several drugs (ex. antihypertension and antihistamine meds), cause liver failure, weight gain and severe lowering of blood pressure. Foods rich in amino acid called tyramine can interact with MAOIs causing rise in BP that can be fatal o Selective Serotonin Reuptake Inhibitors (SSRIs): have several advantages. Many begin experiencing relief within a few weeks, side effects less severe, dont tend to be fatal in overdose, and helpful in wide range of symptoms in addition to depression (anxiety, binge eating, premenstrual symptoms) o SSRIs side effects: increased agitation/nervousness, jittery, hyper, mild tremors, increased perspiration, feel weak, angry, hostile, nausea, stomach cramps, gas, decreased appetite, sexual dysfunction. Appears to be increase in risk for suicide o Buproprion affects norepinephrine and dopamine systems. May be useful for psychomotor retardation, anhedonia, hypersomnia, cognitive slowing, inattention and craving and appears to overcome sexual side effects of SSRIs. Side effects include agitation, insomnia, nausea and seizures Electroconvulsive Therapy for Depression o Electroconvulsive therapy (ECT): series of treatments in which brain seizure induced by passing electrical current through the brain. Most often given to people who havent responded to drug therapies o Decreases metabolic activity in several regions of the brain o Controversial because reports in past of ECT being used as punishment for patients, can lead to memory loss and difficulties in learning new information, relapse rate is high and having electrical current passed through brain is frightening and seems primitive Repetitive Transcranial Magnetic Stimulations (rTMS): repeated, high-intensity magnetic pulses focused on left prefrontal cortex which tends to show abnormally low metabolic activity in some people with depression o Electrical stimulation of neurons can result in long-term changes in neurotransmission across synapses o By stimulating left prefrontal cortex, able to increase neuronal activity which has antidepressant effect o Few side effects (minor headaches) and can remain awake during procedure Vagus Nerve Stimulation (VNS): vagus nerve is part of autonomic nervous system; it carries information from head, neck, thorax, and abdomen to several areas of the brain, including hypothalamus and amygdala, which are involved in depression. In VNS vagus nerve is stimulated. It was originally used to control seizures but realized it improves mood. VNS increases activity in hypothalamus and amygdala, which may have antidepressant effects

Light Therapy: seasonal affective disorder (SAD)- people become depressed during winter months when fewest hours of daylight. Many people with SAD who are exposed to bright lights for a few hours each day during winter months experience relief from depression Light therapy may hep reduce SAD by resetting circadian rhythms, natural cycles of biological activities that occur every 24 hours. People with depression sometimes show dysregulation of circadian rhythms, light therapy might reset circadian rhythms thereby normalizing production of hormones and NTs Another therapy that light therapy decreases levels of hormone melatonin which can increase levels of norephinephrine and serotonin thereby reducing symptoms of depression. Studies suggest it might directly increase serotonin levels Light therapy has minimal side effects Drug Treatments for Bipolar Disorder o Lithium seems to stabilize neurotransmitter systems, including serotonin, dopamine and glutamate. Appears more effective in reducing symptoms of mania than depression. Often prescribed lithium to help curb mania and antidepressant to curb depression o Take lithium to prevent relapses o Some problems with lithium include: differences in rates of absorption so dosage varies greatly, differences between effective dose and toxic dose is small so must be monitored carefully and side effects range from annoying to life-threatening o Side effects of lithium: abdominal pain, nausea, vomiting, diarrhea, tremors, twitches, blurred vision, problems in concentration, can cause diabetes, hypothyroidism, kidney dysfunction, birth defects, and feel washed out o Anticonvulsants: most commonly prescribed are carbamazepine and valproic acid. These reduce symptoms of severe and acute mania. Have effects on NTs o Side effects of carbamazepine include blurred vision, fatigue, vertigo, dizziness, rash, nausea, drowsiness, liver disease o Valproic acid has fewer side effects o Anticonvulsants can cause birth defects o Antipsychotic drugs: used to quell symptoms of severe mania. They reduce functional levels of dopamine and useful in treatment of psychotic manic symptoms o Antipsychotics have many neurological side effects, most severe is tardive dyskinesia, this causes uncontrollable tics and movements of their face and limbs o Calcium channel blockers are safe during pregnancy; fewer side effects than lithium. Side effects include dizziness, headache, nausea, and changes in heart rate

Psychological Treatments for Depression Behaviour therapies focus on increasing number of aversive experiences in individuals life by helping person change their way of interacting with environment and others. theyre designed to be short-term (12 weeks long) First phase of behaviour therapies requires functional analysis of connections between circumstances and depression symptoms. Analysis helps pinpoint behaviours and interaction patterns that need to be focus of therapy and helps client understand connection between their symptoms and daily activities/interactions After identifying circumstances that precipitate depressive symptoms, strategies can be used to make changes, the behaviour therapies strategies fall into 3 categories: 1) Change aspect of environment that are related to depressive symptoms- encourage rewarding activities and avoid depressing activities 2) Teach depressed person skills to change negative circumstances, particularly negative social interactions 3) Teach mood-management skills that can be used in unpleasant situations (ex. relaxation techniques) Cognitive-behavioural therapy: 2 general goals- aims to change negative, hopeless patterns of thinking described by cognitive models of depression and aims to help solve concrete problems in their lives and develop

skills for being more effective so they no longer have deficits in reinforcers described by behavioural theories of depression Cognitive-behavioural therapy designed to be brief (12-15 weeks), focus on specific problems clients believe are connected to depression. Urges clients to take charge of therapy Cognitive Techniques o First step in cognitive-behavioural therapy is help clients discover negative, automatic thoughts they habitually have and understand link between those thoughts and depression o Second step is to help clients challenge their negative thoughts o Third step is to help clients recognize deeper, basic beliefs/assumptions they hold that are feeding their depression and help decide if they truly want to live according to these beliefs Mindfulness techniques help people distance selves from negative thinking and recognize that thoughts dont have to determine behaviours. 3 mindfulness skills categories: 1) Defusion: distancing and letting go of unhelpful thoughts, beliefs and memories 2) Acceptance: accepting thoughts and feelings without judgment, simply allowing them to come and go rather than trying to push them out of awareness or try making sense of them 3) Contact in the present-moment: engaging fully in present experience with attitude of openness and curiosity Behavioural Techniques o Help clients recognize thoughts behind actions then work with them to practice new skills such as assertiveness to cope better Interpersonal Therapy (IPT): look for 4 types of problems as sources of depression: o Grief, loss: help accept feelings and evaluate relationship with lost person, help client invest in new relationships o Interpersonal role disputes: help make decisions about concessions willing to be made and learn better ways of communicating o Role transitions: help develop more realistic perspectives toward roles that are lost and regard new roles in more positive manner o Interpersonal skills deficits: review past relationships, help understand how these might be affecting current relationships; teach social skills such as assertiveness Psychodynamic Therapies: closely observe depressed clients behaviour to analyze sources of depression. Closely observe clients transference to the therapist- ways client treats therapist as though they were someone else- with assumption that transference represents unconscious conflicts and concerns with people in their life. also acknowledge and interpret recollection of events and dreams to find themes. Help client gain insight, accept unconscious concerns and move on. Not very effective

Depression Prevention Community-based interventions Prevent in high-risk adolescents Interventions targeting high-risk groups can help prevent/delay first onsets of depression

CHAPTER INTEGRATION Kendler and Colleagues proposed model: Genetic Factors Dysfunction in NR and neuroendocrine systems Personality characteristics that increase stress response And exposure to stress

Heightened vulnerability to stress | V Encounters with new stress | V Depression