Two broad types of mood disorders:

• Depressive disorders
• Bipolar disorders
DEPRESSIVE DISORDERS

• Fundamental symptom of depression: profound sadness and/or an inability to experience pleasure

• most of us experience sadness -- we tend to say that we are depressed
o But the intensity and duration is not diagnosable
o William Styron
Like anyone else I have always had times when I felt deeply depressed, but this was something
altogether new in my experience—a despairing, unchanging paralysis of the spirit beyond
anything I had ever known or imagined could exist
• When you develop depressive disorder
o tend to focus on flaws and deficits
o Become exhausted in paying attention
o Often view everything in negative light and tend to lose hope
• Physical symptoms:
o Fatigue and low energy
o Physical aches and pains
▪ Symptoms must be profound enough to convince person that he/she is suffering from a
serious medical condition
▪ Even though symptoms have no apparent cause
o Difficulty in falling asleep/ wake up frequently
o Food tasting bland -- appetite gone OR increase in appetite
o Sexual interest disappears
o Psychomotor retardation - thoughts/movements may slow
o Psychomotor agitation - cannot sit still -- pace, fidget, wring hands
• Others:
o Social withdrawal is common
o People neglect their appearance
o Thoughts of suicide

• Major Depressive Disorder (MDD)

o Diagnosis requires the presence of 5 symptoms for at least 2 weeks
▪ Symptoms must include EITHER depressed mood OR loss of interest and pleasure
o MDD is an episodic disorder -- symptoms are present for a period of time and then clear
▪ But some episodes, when left untreated, may stretch for 5 months or longer
 ▪ Sometimes depression becomes chronic -- no longer meet criteria for diagnosis of MDD
but experience subclinical depression
o Episodes tend to recur
▪ once episode clears, person is likely to experience another episode
▪ 2/3 of people who had episode of MDD is likely to experience at least one more episode
▪ Four -- average number of episodes in a lifetime
▪ Risk for experiencing another episode goes up by 16% for every episode that a person
experiences
o Controversy:
▪ Is there a difference between a person with 5 symptoms lasting 2 weeks VS person who
has three symptoms lasting for 10 days (this meets criteria for subclinical depression)

• Persistent Depressive Disorder (Dysthymia)

o Chronically depressed -- more than half the time for at least 2 years
▪ People feel blue or derive little pleasure from usual activities and pastimes
▪ At least two of other symptoms of depression
o DSM-IV-TR differentiates chronic MDD from dysthymia but not in DSM-5
▪ Combination of chronic forms of depression places emphasis on chronicity of symptoms
▪ Chronicity -- stronger predictor of poor outcome than number of symptoms
▪ Research found that 95% of people with dysthymia developed MDD over a 10-year period
• Epidemiology and Consequences of Depressive Disorders
o MDD one of the most prevalent psychiatric disorders
o 16.2% of people meet criteria for diagnosis of MDD
▪ Persistent depressive disorder rarer than MDD -- 2.5 % of people meet criteria
o MDD twice as common among women
o MDD three times as common among people who are impoverished (SES matters)
o Prevalence of depression varies across cultures
▪ People who moved to the US from Mexico have lower rates of MDD than people who
were of Mexican descent who were born in the United States
▪ The resiliency of people who are able to immigrate could be protective
o Symptoms of depression also vary across cultures
▪ People in South Korea less likely to describe sad mood or suicidal thoughts as compared to
people in the US
▪ Headache complaints more common in Latino culture
▪ Weakness, fatigue, and poor concentration more common in some Asian cultures
▪ One factor maybe distance from the equator
▪ Rates of winter depression or seasonal affective disorder are higher when farther
from the equator
▪ There is also correlation of per capita fish consumption with depression
▪ Japan and Iceland have lower rates of MDD and bipolar disorder
o In most countries, age of onset of MDD decreased
▪ Maybe due to social changes that have occurred over the past 100 years
▪ Example: support structures are often absent for people today
▪ Depression in children often result in somatic complaints (headaches or stomachaches)
▪ Older generations -- characterized by distractability and complaints of memory loss
o MDD and persistent depressive disorder often associated/comorbid with other psychological
problems
▪ 60% of people who meet criteria for MDD will also meet criteria for diagnosis of anxiety
disorder at some point
o Depression as a risk
▪ One of world's leading cause of disability
▪ 31 billion dollars lost per year in productivity in US
o Persistent depressive disorder is not a less severe disorder than MDD
 ▪ Study found that average duration of DSM-IV-TR dysthymic symptoms was more than 5
years
▪ Chronicity takes a toll -- more likely to require hospitalization, to attempt suicide, and to
be impaired in functioning than people with MDD

• Gender differences in depression

o Ratio does not hold in some cultural groups (example: between Jewish adults)
o Gender ratio in depression is more pronounced in cultures with more traditional gender roles
▪ Twice as many girls as boys are exposed to childhood sexual abuse
▪ Women are exposed to chronic stressors such as poverty and caretaker responsibilities
▪ Acceptance of traditional roles among girls -- intensify self-critical attitudes about
appearance
▪ Girls worry more about body image (a factor tied to depression)
▪ Effects of female hormones -- could change reactivity of HPA axis (system which guides
reaction to stress)
▪ Social roles promote emotion-focused coping among women -- which extends duration of
sad mood
▪ Women tend to ruminate about moods -- may intensify and prolong sad mood
▪ Men tend to use distracting or action-focused coping that shake off the sad mood

• Seasonal Affective Disorder: Winter Blues

o Criteria:
▪ Person experiences depression during two consecutive winters and symptoms clear during
the summer
o More common in northern climates
o Mammals living in the wild -- slower metabolism is lifesaver
▪ But for humans -- this mechanism might contribute to seasonal affective disorder
o It is believed that seasonal affective disorder is related to changes in levels of melatonin in the
brain
▪ Melatonin is only released during dark periods
▪ People with SAD show greater changes in melatonin in the winter
o SAD responds to antidepressant medications and cognitive behavioral therapy
o Winter blue likely to remit with 30 minutes of exposure to bright light each morning
▪ Light therapy may also help relieve depression without seasonal pattern

• Depression and cardiovascular disease

o Cardiovascular health predict depression AND depression can also predict cardiovascular health
▪ In a meta-analysis - depression was related to 90% increase in onset of cardiovascular
disease and 60% increase in the severity of cardiovascular disease over time
o Reasons for overlap of depression and cardiovascular outcomes:
▪ Both conditions involve stress reactivity
▪ Changes in neurotransmitters, cortisol regulation, immune function, and balance of
sympathetic to parasympathetic function

BIPOLAR DISORDERS

• Has three forms

• Manic symptoms -- defining feature of each disorder
• Can be differentiated by how severe and long-lasting the manic symptoms are
• "bipolar" -- most people who experience mania also experience depression during their lifetime
(mania and depression are considered OPPOSITE POLES)
• Mania - state of intense elation or irritability accompanied by other symptoms
 o People act and think in ways that are highly unusual compared to typical selves
o People may become louder and make incessant stream of remarks
o Difficult to interrupt and may shift rapidly from topic-to-topic ---> FLIGHT OF IDEAS
o Excessively confident --- oblivious to danger, imprudent sexual activities, overspending, and
reckless driving
• Hypomania
o Hypo -- "under" ---> less extreme than mania
o Involves change in functioning that does not cause serious problems
o May feel social, flirtatious, energized, and productive

• Bipolar I Disorder
o Formerly known as "manic-depressive disorder"
o Include single episode of mania
o More than half of people with bipolar I disorder experience four or more episodes

• Bipolar II Disorder
o Milder form of bipolar disorder
o Person must have experienced at least one major depressive episode and at least one episode
of hypomania

• Cyclothymic Disorder
o Also known as "cyclothymia"
o A chronic mood disorder (like persistent depressive disorder)
o Symptoms be present for at least 2 years among adults (1 year in children and adolescents)
▪ Has frequent but mild symptoms of depression
▪ Alternating with mild symptoms of mania
 • Epidemiology and Consequences of Bipolar Disorders
o Bipolar I disorder is much rarer than MDD
▪ 0.6% or 6 out of 1000 people met the criteria for bipolar I disorder across 11 countries
▪ Higher rates in the US -- 1% of people experience the disorder
▪ Culture may shape tendencies to label behaviors as manic symptoms
▪ Bipolar I is among most severe forms of mental illnesses
o Bipolar II affects 0.4 to 2% of people
o Cyclothymic disorder affects 4% of people
o Bipolar disorders occur equally often in men and women
▪ However, women experience more depressive episodes
▪ 2/3 of people with bipolar disorder meet diagnostic criteria for comorbid anxiety disorder
▪ More than 1/3 report history of substance abuse
▪ High risk for range of other medical conditions (cardiovascular disease, diabetes mellitus,
obesity, and thyroid disease)
o Hypomania often associated with creativity and achievement
o Creativity and mood disorders
▪ Kay Redfield Jamison (psychologist)
▪ Michelangelo, van Gogh, Tchaikovsky, Schumann, Gauguin, Tennyson
▪ Many people assume that manic state fosters creativity through elated mood, increased
energy, rapid thoughts, and heightened ability
▪ BUT extreme mania lowers creative output
▪ Reducing manic symptoms should help creativity

Subtypes of Depressive Disorders and Bipolar Disorders

• Mood disorders - highly heterogeneous
o People may show different symptoms but diagnosed with same disorder
• To address this, DSM-5 provides criteria for dividing MDD and bipolar disorders into number of
specifiers (subtypes)
o Rapid cycling (only for bipolar disorder) and seasonal pattern
▪ Refer to overall pattern of episodes over time
o Other specifiers describe the current episode
▪ Mood-congruent/mood incongruent psychotic features
▪ Catatonia
ETIOLOGY OF MOOD DISORDERS

Neurobiological Factors in Mood Disorders

• Genetic Factors
o MDD heritability estimates of 37% in twin studies
o Bipolar disorder heritability estimate of 93%
o Identified 166 genetic loci linked with bipolar disorder and MDD -- but only 6 loci have been
replicated
o Polymorphism in DRD4.2 gene (influences dopamine function) related to MDD
• Neurotransmitters
o Evidence do not support that absolute levels of neurotransmitters were important in mood
disorders
▪ SEEMS LIKE effective antidepressants promote immediate increase in levels of serotonin,
norepinephrine and/or dopamine
▪ BUT antidepressants take 7 to 14 days to relieve depression
▪ By this time neurotransmitter levels have already returned to their previous state
 o Receptor sensitivity implicated
▪ People with depression are less responsive to drugs that increase dopamine levels
▪ Dopamine plays major role in sensitivity of reward system in the brain
▪ May explain deficits in pleasure, motivation, and energy in MDD
▪ People with bipolar disorder may have overly sensitive dopamine receptors
▪ Drugs that increase dopamine levels --- trigger manic symptoms
▪ People vulnerable to depression may have less sensitive serotonin receptors
▪ Researchers depleted tryptophan (a serotonin precursor) which caused temporary
depressive symptoms among people with history of depression or family history of
depression
▪ Bipolar disorder also related to less sensitive serotonin receptors
• Brain structures
o Types of brain imaging studies
▪ Structural studies - whether brain region is smaller or larger among people with a disorder
▪ Functional activation studies - whether there is change in the activity of a brain region
o Brain structures involved in experiencing and regulating emotion (in episodes of MDD)
▪ Amygdala - assess how emotionally important a stimulus is
▪ Damage to amygdala - fail to react with fear to threatening stimuli
▪ People with current MDD have more intense and sustained reaction in amygdala
when shown negative words/pictures
▪ Amygdala hyperactivity to emotional stimuli in depression might be part of
vulnerability to depression rather than just aftermath of being depressed
▪ Subgenual anterior cingulate
▪ Important in emotional regulation
▪ When stimulated by electrodes, decreased activity in the subgenual anterior
cingulate -- reported immediate relief from depressive symptoms
▪ Dorsolateral prefrontal cortex
▪ Also important in emotional regulation
▪ Diminished activity during exposure to emotional stimuli
▪ Hippocampus
▪ Also important in emotional regulation
▪ Diminished activity during exposure to emotional stimuli
o Brain structures implicated in MDD also appear to be involved in bipolar disorder
o Striatum - implicated in reactions to reward
▪ This region is overly activated during mania
o People with bipolar disorder have deficits in the membranes of their neurons
▪ These influence how readily these neurons can be activated
▪ Protein kinase C --- role in function of receptors and cell membranes
▪ abnormally high activity among people with mania
• Neuroendocrine system
o HPA (hypothalamic-pituitary-adrenocortical axis) may be overly active during episodes of MDD
▪ Amygdala sends signals that activate HPA axis
o People with Cushing's syndrome which causes oversecretion of cortisol experience depressive
symptoms
o People who are depressed (but no Cushing's syndrome) -- cortisol levels are poorly regulated
▪ Dexamethasone (which suppresses cortisol secretion) does not work in people with MDD
▪ Sign of poor regulation of HPA axis
▪ Dexamethasone suppression test (dex/CRH)
▪ Researchers administer both dexamethasone and corticotropin-releasing hormone
o Long term excesses of cortisol linked to damage to hippocampus
o Bipolar disorder also characterized by poorly regulated cortisol system
Social factors in depression
• Some people may be more vulnerable to stress than others
o Diathesis-stress models: ALWAYS consider both preexisting vulnerabilities (diatheses) and
stressors
o Diatheses could be biological, social or psychological
▪ Like lack of social support
▪ Interpersonal problems within the family likely to trigger depression
▪ Expressed emotion (EE) - family member's critical or hostile comments toward or
emotional involvement with person with depression
▪ High EE -- relapsed within 1 year

Psychological factors in depression

• Neuroticism - personality trait that involves tendency to react to events with greater-than-average
negative affect
o May predict onset of depression
o Also associated with anxiety and dysthymia
• Cognitive theories
o Beck's theory
▪ The negative triad: negative views of self, world, and future
▪ World -- person's corner of the world or the situations he/she faces
▪ Childhood with depression acquired negative schema
▪ through experiences such as loss of parent, social rejection of peers, or depressive
attitude of parent
▪ SCHEMAS are different from conscious thoughts -- schemas are an underlying set of
beliefs that operate outside of a person's awareness
▪ Schemas cause cognitive biases when activated
▪ Cognitive biases are tendencies to process information in certain negative ways
▪ People with depression may be overly attentive to negative feedback about
themselves
▪ They may fail to notice positive feedback
▪ Tested using Dysfunctional Attitude Scale (DAS)
▪ Items concerning whether you would consider yourself as worthwhile or lovable
▪ People demonstrate negative thinking on scales like the DAS during depression
o Hopelessness Theory
▪ Most important trigger of depression is hopelessness
▪ Expectation that desirable outcomes will not occur
▪ Expectation that the person has no responses available to change this situation
▪ Hopelessness contribute to hopelessness depression
▪ Symptoms: decreased motivation, sadness, suicidality, decreased energy,
psychomotor retardation, sleep disturbance, poor concentration, negative cognitions
▪ People with attributional style which leads them to believe that negative life event was
due to stable and global causes are likely to become hopeless
▪ Attribution -explanation a person forms about why a stressor has occurred
▪ Can be stable (permanent) vs. unstable (temporary) causes
▪ Can be global (relevant to many life domains) vs. specific (limited to one area)
causes
▪ Low self esteem promotes hopelessness too
▪ Tested using Attributional Style Questionnaire (ASQ)
 3. Rumination Theory
o Rumination - tendency to repetitively dwell on sad experiences and thoughts
▪ Most detrimental form: to brood or to regretfully ponder why a sad event happened
o Tendency to ruminate predicted onset of major depressive episodes
o Rumination interferes with problem solving and increases negative mood

Neurobiological and Psychosocial etiology of depression

• Serotonin transporter gene
o Presence of polymorphism (at least one short allele) in gene is associated with poor
serotonergic function
o One short allele -- elevated reactivity to stress
• Greater risk for depression after stressful life event than those w/o polymorphism

Social and psychological factors in bipolar disorder

• Depression in bipolar disorder
o Triggers of depressive episodes in bipolar disorder appear similar to triggers of MD episodes
• Predictors of mania
o Reward sensitivity
▪ People with bipolar disorder describe themselves as highly responsive to rewards
▪ Life events that involve attaining goals promote increases in symptoms
▪ May trigger cognitive changes in confidence --- which then spiral into excessive goal
pursuit
o Sleep deprivation
▪ Participants who were experiencing bipolar depression were asked to stay up all night
▪ The following morning 10% were experiencing mild symptoms of mania

TREATMENT OF MOOD DISORDERS

Psychological Treatment of Depression

 • Interpersonal Therapy (IPT)
o Examine major interpersonal problems (e.g. role transitions, interpersonal conflicts,
bereavement, interpersonal isolation)
o Therapist and patient focus on one or two issues -- goal is to make person identify his/her
feelings about these issues, make important decisions, make changes to resolve problems
o 16 sessions typically -- very brief
o Studies show IPT effective in relieving MDD and prevents relapse when continued after
recovery
▪ Effective among adolescents, postpartum women
▪ Effective in treatment for dysthymia

• Cognitive Therapy (CT)

o Aims to alter maladaptive thought patterns
o Beck's emphasis on cognitive restructuring
▪ Cognitive restructuring - persuading the person to think less negatively
o Beck also includes Behavioral Activation
o There are computer-administered versions of CT
o Mindfulness-based cognitive therapy (MBCT)
▪ An adaptation of CT which focuses on relapse prevention after successful treatment for
recurrent episodes
▪ ASSUMPTION: person is vulnerable to relapse because of repeated associations between
sad mood and patterns of self-devaluative, hopeless thinking during major depressive
episodes
▪ GOAL: teach people to recognize when they start to become depressed
▪ Try to adopt "decentered" perspective
▪ View thoughts as "mental events" rather than aspects of the self
▪ "I am not my thoughts"

• Behavioral Activation (BA) Therapy

o Based on idea that many risk factors for depression result in low levels in positive reinforcement
o GOAL: to increase participation in positively reinforcing activities to disrupt the spiral of
depression, withdrawal, and avoidance

• Behavioral Couples Therapy

o GOAL: to improve communication and relationship satisfaction

Psychological Treatment of Bipolar Disorder

• Psychoeducational approaches
o People learn about the symptoms of the disorder, expected time course, biological and
psychological triggers for symptoms, treatment strategies
o Can help people to adhere to treatment

• Cognitive Therapy and Family-focused Therapy (FFT)

o FFT aims to educate family about illness, enhance family communication, and develop problem
solving skills

Biological Treatment of Mood Disorders

• Electroconvulsive Therapy (ECT) for Depression

o Used to treat MDD that has not responded to medication
o Inducing a momentary seizure and unconsciousness
 o Bilateral ECT (electrodes on each side of forehead) VS. Unilateral ECT (current passes through
on the nondominant cerebral hemisphere)
▪ Lesser side-effects if done on the nondominant side
o ECT more powerful than antidepressant medications for treatment of depression
• Medications for Depressive Disorders
o Categories of antidepressants
▪ Monoamine oxidase inhibitors (MOAIs)
▪ Least used because of potentially life-threatening side effects if combined with
certain food/beverages
▪ Tricyclic antidepressants
▪ Selective serotonin reuptake inhibitors (SSRIs)
▪ Most commonly prescribed antidepressants
o Relapse common after drugs are withdrawn

Psychotherapy may take longer but may help people learn skills that they can use after treatment is
finished
Antidepressants work more quickly -- provides immediate relief

• Medications for Bipolar Disorder

o Mood stabilizing medications -- medications that reduce manic symptoms
o Lithium - first identified mood stabilizer
▪ High levels of lithium may be toxic -- patients have to have regular blood tests
o Anticonvulsants (antiseizure) medications
▪ Such as divalproex
o Antipsychotic medications
▪ Such as olanzepine

SUICIDE

Suicidal ideation - thought of killing oneself

Suicide attempts - involve behaviors that are intended to cause death but do not result in death

Suicide - involves behaviors that are intended to cause death and actually do so

Nonsuicidal self-injury (NSSI) - behaviors that are meant to cause immediate bodily harm but are not
intended to cause death
• Person did not intend death
• Behavior is designed to immediately cause injury
o Injury seems to help quell other negative emotions (i.e. anger)
o Some report feeling satisfied after self-injury because they have given themselves punishment
that they believe they deserved
o Behavior may also be reinforcing interpersonally

Epidemiology of Suicide and Suicide Attempts

• 1 per 10,000 suicide rate in the US
• 1 in 20 suicide attempts result in death
• 9% people worldwide report suicidal ideation; 2.5% report at least one suicide attempt
• Men are 4 times likely than women to kill themselves
• Women are more likely than men to make suicide attempts that do not result in death
Models of Suicide

• Psychological disorders
o More than half of those who try to kill themselves are depressed at the time of the act
o 15% people who have been hospitalized with depression ultimately die from suicide
• Neurobiological models
o Twin studies suggest heritability of 48% for suicide attempts
o Serotonin dysfunction may increase risk of violent suicide
• Social Factors
o Media coverage of a celebrity suicide is much more likely to spark an increase in suicidality than
coverage of noncelebrity suicide
o Social isolation and lack of social belonging may predict suicidal ideation and behavior
• Psychological models
o Suicide related to poor problem solving
o High levels of hopelessness associated with four-fold elevation in risk of suicide
o Reasons for Living Inventory
▪ Tap into what is important to the person
▪ More reasons to live -- tend to be less suicidal
o More impulsive, more likely to attempt suicide

Preventing Suicide
• Permission to talk about suicide may relieve a sense of isolation
• Marsha Linehan's dialectical behavior therapy
• Cognitive behavioral approaches
o Improve problem solving and social support to reduce feelings of hopelessness
• Thomas Sasz: impractical and immoral to prevent suicide