DEPRESSION AND

BIPOLAR DISORDERS

Dept of Psychiatry
University of Zambia
I. Introduction
II. Clinical features of mood disorders
A. Description of mood disorders
B. Diagnostic criteria
C. Epidemiology and natural history
III. Effects of treatments on mood disorders
A. Long-term outcomes of mood disorders and
the 5 R's of antidepressant treatment
B. Search for subtypes of depression that predict
response to antidepressants
C. The good news and the bad news about
antidepressant treatments
D. Longitudinal treatment of bipolar disorder
E. Mood disorders across the life cycle: When do
antidepressants start working?
 IV. Biological basis of depression
A. Monoamine hypothesis
B. Monoaminergic neurons
1. Noradrenergic neurons
2. Dopaminergic neurons
3. Serotonergic neurons
C. Classical antidepressants and the
monoamine hypothesis
D. Neurotransmitter receptor hypothesis
V. Summary
Clinical Features of Mood Disorders
 Depression and mania are often seen as opposite ends of an
affective or mood spectrum.

 Classically, mania and depression are "poles" apart, thus

generating the terms unipolar depression, in which patients
just experience the down or depressed pole and bipolar
disorder, in which patients at different times experience
either the up (manic) pole or the down (depressed) pole. In
practice, however, depression and mania may occur
simultaneously, which is called a "mixed" mood state. Mania
may also occur in lesser degrees, known as "hypomania," or
may switch so fast between mania and depression that it is
called "rapid cycling.”
What is Depression?
 Depression is an emotion that is universally
experienced by virtually everyone at some
time in life.
 Distinguishing the "normal" emotion of
depression from an illness requiring medical
treatment
 Depression is not a disease but a deficiency

of character, which can be overcome with

effort.
Public perceptions of mental illness
 71% Due to emotional weakness
 65% Caused by bad parenting
 45% Victim's fault; can will it away
 43% Incurable
 35% Consequence of sinful behaviour
 10% Has a biological basis; involves

the brain
Medical Practioners perceptions of
mental illness
 Stigma and misinformation can also extend
into medical practice, where many depressed
patients present with medically unexplained
symptoms.
 "Somatization"

When a person uses physical symptoms to

express emotional distress.
 Major reason for misdiagnosis of mental

illness
 Many depressed patients with somatic
complaints are considered to have no real
or treatable illness and thus are not treated
for a psychiatric disorder once medical
illnesses are evaluated and ruled out.
 In reality, however, most patients with diffuse

unexplained somatic symptoms in primary

care settings either have a treatable
psychiatric illness (e.g., anxiety or depressive
disorder) or are responding to stressful life
events.
 Such patients do not generally have a genuine

somatization disorder in which "their

symptoms are really all in their mind."
How to recognize and treat ?
 Accepted, standardized diagnostic criteria are
used to separate "normal" depression caused
by disappointment or "having a bad day" from
the disorders of mood.
 Such criteria also are used to distinguish

feeling good from feeling "better then good“

(hypomania) and expansive and irritable that
amount to mania
Depression is a syndrome
Clusters of symptoms in depression:
 Vegetative
 Cognitive
 Impulse control
 Behavioral
 Physical (somatic)
 vegetative features: sleep, appetite, weight,
and sex drive;
 cognitive features:

attention span, frustration tolerance,

memory, negative distortions;
 Impulse control:

suicide and homicide;

 behavioral features: motivation, pleasure,

interests, fatigability; and

 physical {or somatic) features: headaches,

stomach aches, and muscle tension

Epidemiology and Natural history
 What is the incidence of major depressive
disorder versus bipolar disorder?
 How many people have the condition at the

present time, and how many in their

lifetimes?
 Are individuals with mood disorders being

identified and treated, and if so, how?

 Also: What is the outcome of their treatment?
 What is the natural history of their mood

disorder without treatment and how is this

affected by treatment?
Epidemiology
 The incidence of depression is about 5% of the
population, whereas the incidence of bipolar
disorder is about 1%.
 Unfortunately, only about one-third of individuals
with depression are in treatment, not only because
of under recognition by health care providers but
also because individuals often conceive of their
depression as a type of moral deficiency, which is
shameful and should be hidden. Individuals often
feel as if they could get better if they just "pulled
themselves up by the bootstraps"
Epidemiology
 The reality is that depression is an illness, not
a choice, and is just as socially debilitating as
coronary artery disease and more debilitating
than diabetes mellitus or arthritis.
 Furthermore, up to 15% of severely
depressed patients will ultimately commit
suicide. Suicide attempts are up to ten per
hundred subjects depressed for a year, with
one successful suicide per hundred subjects
depressed for a year.
Epidemiology
Conclusions :
 Mood disorders are common, debilitating, life

threatening illnesses, which can be

successfully treated but which commonly are
not treated.
DSM-IV Criteria for Mania
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood,
lasting at least 1 week (or any duration if hospitalization is necessary).
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 (e.g., feels rested after only 3 hours of sleep).
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).
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.
 Risk factors for major depression
 Sex Major depression is twice as likely in women
 Age Peak age on onset is 20—40 years
 Family history 1.5 to 3 times higher risk with positive history
 Marital status Separated and divorced persons report higher
rates
Married males lower rates than unmarried
Married females higher rates than unmarried
 Postpartum An increased risk for the 6-month period
following childbirth
 Negative life events Possible association
 Early parental death Possible association
Suicide and Major Depression: the rule of sevens

 One out of seven with recurrent depressive

illness commits suicide
 70% of suicides have depressive illness
 70% of suicides see their primary care

physician within 6 weeks of suicide

 Suicide is the seventh leading cause of death

in the United States

The hidden cost of not treating major depression

 Mortality 30,000 to 35,000 suicides per year

 Fatal accidents due to impaired concentration and attention
 Death due to illnesses that can be sequelae (e.g., alcohol abuse)
 Patient morbidity
 Suicide attempts
 Accidents
 Resultant illnesses
 Lost jobs
 Failure to advance in career and school
 Substance abuse
 Societal costs
 Dysfunctional families
 Absenteeism
 Decreased productivity
 Job-related injuries
 Adverse effect on quality control in the workplace
Treatment Why Necessary?