PSCY Essay

Depressive and Bipolar Disorders SSY 230: Lecture 12

Depressive Disorders

A depressive disorder is characterized by periods in which,

among other symptoms, an individual experiences an

unusually intense sad mood. The disorder’s essential

element—this sad mood—is known as dysphoria.

Major Depressive Disorder

Major depressive disorder consists of acute but time-limited periods of depressive symptoms that are called major depressive episodes.

Major depressive disorder can be diagnosed with a range of other disorders including, for example, personality disorders, substance use disorders, and anxiety disorders. A number of conditions can mimic major depressive disorder, including schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder. The clinician must rule out these specific disorders before assigning the diagnosis of major depressive disorder to the client.

In the United States, the lifetime prevalence of major depressive disorder is 16.6 percent of the adult population. The below figure summarizes the 1-year prevalence of major depressive episodes along with variations by sex, age, and race/ethnicity.

As you can see from this figure, the highest 1-year prevalence of major

depressive episode is found among individuals 18–25 years of age, and

the numbers decrease after that to 4.8 percent at ages 50 and older.

These generational differences may reflect a number of factors, including

a tendency for younger adults to be more open about reporting their

symptoms, and the lower survival rates into the later decades of people

with major depressive disorder. Age differences in the nature of reported

symptoms may also influence prevalence statistics, in that depressive

symptoms may be reported as physical rather than psychological

concerns in older adults.

Criteria for a Major Depressive Episode

For most of the time during a 2-week period, a person experiences at least five or more of the first nine symptoms in addition to the last two. He or she must experience a change from previous functioning, and at least one of the first two symptoms must be present. During this 2-week period, most of these symptoms must be present nearly every day.

● Depressed mood most of the day

● Markedly diminished interest or pleasure in all or most daily activities

● Significant unintended weight loss or unusual increase or decrease in appetite

● Insomnia or hypersomnia

● Psychomotor agitation or retardation observable by others

● Fatigue or loss of energy

● Feelings of worthlessness or excessive or inappropriate guilt

● Difficulty maintaining concentration or making decisions

● Recurrent thoughts of death or having suicidal thoughts, plans, or attempts

● The symptoms are not attributable to a medical condition or use of a substance

● The symptoms cause significant distress or impairment

Persistent Depressive Disorder (Dysthymia)

The mood disturbance occurring with major depressive disorder may take a chronic, enduring form. People with persistent depressive disorder (dysthymia) have, for at least 2 years (1 year for children and adolescents), a more limited set of the symptoms that occur with major depressive disorder, including sleep and appetite disturbances, low energy or fatigue, low self-esteem, difficulty with concentration and decision making, and feelings of hopelessness. However, people with persistent depressive disorder currently do not meet the criteria for a major depressive episode, which requires that the client meet five of the criteria on slide 4.

Despite the fact that people with persistent depressive disorder do not experience all the symptoms of a major depressive episode, they are never free of their symptoms for longer than 2 months. Moreover, they are likely to have other serious psychological disorders, including a heightened risk for developing major depressive disorder, personality disorder, and substance use disorder.

Approximately 2.5 percent of the adult population will develop dysthymic disorder in the course of their lives, with a peak (as of the early 2000s) in the 45- to 59-year-old age group. As is true for major depressive disorder, dysthymic disorder symptoms take on a different form in older adults, who are more likely to report disturbances in physical than in psychological functioning .

Disruptive Mood Dysregulation Disorder

The diagnosis of disruptive mood dysregulation disorder is used for children who exhibit chronic and severe irritability and have frequent temper outbursts that occur, on average, three or more times per week over at least 1 year and in at least two settings. These outbursts must be developmentally inappropriate, meaning that, for example, in an older child or young teen they take the form of the behavior of a much younger child.

Between outbursts, children with this disorder remain angry or at least extremely irritable. The criteria specify that the diagnosis should not be made for the first time for children whose first episode occurs when they are younger than 6 or older than 18. However, either by directly observing the child or from the child’s history, the clinician must determine that the disorder had its onset before the age of 10. In other words, a teen of 13 must be reported by parents or teachers, for example, to have been subject to angry episodes prior to turning 10 years old.

The authors of DSM-5 recognized a potential criticism of this disorder that might be characterized as pathologizing a child’s “temper tantrums,” but they believed it was important to have a disorder earmarked for children and teens who in the past would have been diagnosed with bipolar disorder. Follow-up data of children who show this pattern of extreme irritability and angry outbursts suggest that, rather than developing bipolar disorder, they are at risk of developing depressive and/or anxiety disorders when they reach adulthood.

Premenstrual Dysphoric Disorder

Women who experience depressed mood or changes in mood, irritability, dysphoria, and anxiety during the premenstrual phase that subside after the menstrual period begins for most of the cycles of the preceding year may be diagnosed with premenstrual dysphoric disorder (PMDD).

This disorder was in the Appendix (it was not a diagnosable condition) in DSM-IV-TR. By making this disorder part of the standard psychiatric nomenclature, the DSM-5 authors believed that better diagnosis and treatment could result for women who experience its symptoms.

Critics argue that the PMDD diagnosis pathologizes the normal variations in mood that can occur over the course of a woman’s monthly menstrual cycle. However, the counterargument is that the majority of women do not experience monthly mood alterations so severe that they would show such extreme symptoms. Including PMDD as a diagnosis allows those with these severe episodes of depression to receive treatment that might not otherwise be available to them.

Disorders Involving Alterations in Mood

Two sets of disorders are characterized by alterations in mood that go beyond everyday variations in levels of sadness or happiness.

These are bipolar disorder and cyclothymic disorder.

Bipolar disorder includes an intense and disruptive experience of a manic episode.

During a manic episode, the individual may experience unusually high levels of euphoria, which is the feeling state of an abnormally positive mood.

Bipolar Disorder

Clinicians diagnose people who have manic episodes with bipolar disorder, a term that has replaced “manic depression.” An individual must experience a manic episode in order for a clinician to diagnose bipolar disorder. The diagnosis does not require that the individual has ever experienced a major depressive episode.

The two major categories of bipolar disorder are bipolar I

and bipolar II. A diagnosis of bipolar I disorder describes a

clinical course in which the individual experiences one or

more manic episodes with the possibility, although not the

necessity, of experiencing one or more major depressive

episodes. In contrast, a diagnosis of bipolar II disorder

means the individual has had one or more major

depressive episodes and at least one hypomanic episode.

The criteria for a hypomanic episode are similar to those

for a manic episode but require a shorter duration (4 days

instead of 1 week).

Criteria for a Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy must last at least 1 week and the symptoms must be present most of the day, nearly every day (or for any duration if hospitalization is necessary).

During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms are present to a significant degree (four if the mood is only irritable) and represent a noticeable change from usual behavior:

● inflated self-esteem or grandiosity

● decreased need for sleep (the client feels rested after, say, only 3 hours of sleep)

● more talkative mood than usual or pressure to keep talking

● flight of ideas or subjective experience that thoughts are racing

● distractibility (attention is too easily drawn to unimportant or irrelevant external stimuli), as reported or observed ● increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation ● excessive engagement in activities that have high potential for painful consequences (such as unrestrained buying sprees, sexual indiscretions, or foolish business investments)

This episode must represent a clearly observable change in functioning but not be severe enough to require hospitalization to prevent harm to self or others.

Bipolar Disorder

Individuals who are in a manic, hypomanic, or major depressive episode may show features of the opposite pole but not to an extreme enough degree to meet the relevant diagnostic criteria for bipolar disorder. For example, people in a manic episode may also report feeling sad or empty, fatigued, or suicidal.

DSM-5 uses a specifier of “mixed features” to apply to cases

in which an individual experiences episodes of mania or

hypomania when depressive features are present, and to

episodes of depression in the context of major depressive

disorder or bipolar disorder when features of

mania/hypomania are present. The “mixed” category accounts

for individuals with bipolar disorder who may show features

of both depression and mania/hypomania, either

simultaneously or nearly simultaneously.

Bipolar Disorder

Bipolar disorder has a lifetime prevalence rate of 3.9 percent in the U.S. population. Of those diagnosed with bipolar disorder in a given year, nearly 83 percent (2.2 percent of the adult population) have cases classified as severe. At least half of all cases begin before a person reaches the age of 25. Approximately 60 percent of all individuals with bipolar disorder can live symptom-free if they receive adequate treatment. This means a large percentage continue to experience symptoms. According to one estimate, over the course of a 5-year period, people with bipolar disorder feel that their mood is normal only about half the time.

Of all psychological disorders, bipolar disorder is the most likely to occur in people who also have problems with substance abuse. People with both bipolar and substance use disorders have earlier onset of bipolar disorder, more frequent episodes, and higher risk of developing anxiety- and stress-related disorders, aggressive behavior, problems with the law, and risk of suicide.

People with bipolar disorder are also at risk of more severe chronic health problems than others their own age. They have higher rates of heart disease and diabetes and higher levels of cholesterol. These may be the reasons that, according to a comprehensive population study conducted in Denmark, bipolar disorder is associated with lower life expectancy across a variety of causes. In addition to higher mortality due to illness, people with bipolar disorder also have elevated rates of suicide and other forms of violent death. Their risks are similar in magnitude to those found in people with schizophrenia; the gap between their mortality and that of the general population has also widened in the past decade.

Bipolar Disorder Rapid Cycling

Clinicians diagnose people as having bipolar disorder, rapid cycling if they have had four or more episodes within the previous year that meet the criteria for manic, hypomanic, or major depressive disorder.

In some individuals, the cycling may occur within 1 week or even 1 day. The factors that predict rapid cycling include earlier onset, higher depression scores, higher mania scores, and lower global assessment of functioning.

A history of rapid cycling in the previous year and use of antidepressants also predict rapid cycling. Medical conditions such as hypothyroidism, disturbances in sleep/wake cycles, and use of antidepressant medications can also contribute to the development of rapid cycling .

Individuals who experience bipolar disorder, rapid cycling are at higher risk of suicide than others with bipolar disorder, and also of a longer duration of the disorder.

Cyclothymic Disorder

Cyclothymic disorder is characterized by alternations between dysphoria and briefer, less intense, and less disruptive euphoric states called hypomanic episodes.

People with this disorder have met the criteria for a hypomanic episode many times over a span of at least 2 years (1 year in children and adolescents) and also experience numerous periods of depressive symptoms but never meet the criteria for a major depressive episode.

During their respective time frames, adults, children, or adolescents have never been without these symptoms for more than 2 months at a time.

Biological Perspective

Supporting the role of genetics, it has long been known that first-degree relatives of people with major depressive disorder are 15 to 25 percent more likely to have the disorder than are people who do not have this close biological relationship. Based on the existing literature, major depressive disorder has an estimated heritability of 37 percent , with rates higher in women than men (approximately 40 percent for women vs. 30 percent for men). Compared to major depressive disorder, bipolar disorder has an even stronger pattern of genetic inheritance, with an estimated heritability of 60 to as high as 85 percent.

Moving from genetics to the biochemical abnormalities, increasing evidence points to the role of altered serotonin and norepinephrine levels in causing the mood changes associated with major depressive disorder. However, not everyone with genetic predisposition shows these mood-changing alterations in neurotransmitter levels. If exposed as adults to life stressors and other environmental factors, the genetically predisposed can experience a series of changes in the neural pathways active in regulating mood.

These alterations in neurotransmitters can further influence the mood of individuals with major depressive disorder by causing activation within the brain’s internally based attentional circuits. Rather than focus their attention outward, individuals with major depressive disorder become overly preoccupied with their thoughts and feelings. Because areas within the brain’s inner network responsible for emotional processing are also disrupted, this set of changes causes the depressed person to turn those thoughts and feelings in a negative direction.

Brain scan and neuropsychological testing of individuals with bipolar disorder suggest that they have difficulties in attention, memory, and executive function consistent with abnormalities in the prefrontal lobe. These changes may have their origins in altered genetics which, in turn, place individuals at risk when they are exposed to life stressors, particularly early in life.

Antidepressant Medications

At present, biological interventions for mood disorders target not the genetic abnormalities themselves but the effect of those abnormalities on neurotransmitters. Therefore, antidepressant medication is the most common form of biologically based treatment for people with major depressive disorder. Clinicians prescribe antidepressants from four major categories: selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs).

The choice of antidepressant depends primarily on the clinician’s preference for a particular class of medications. Ultimately, the medications the individual receives may be selected by trial and error as the clinician attempts to identify which work best and produce the fewest side effects.

SSRIs block the uptake of serotonin, making more of this crucial neurotransmitter available to act at the receptor sites of receiving neurons. SSRIs include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and sertraline (Zoloft). Balancing their positive effects on mood are their side effects. The most commonly reported are nausea, agitation, and sexual dysfunction. A newer class of antidepressants are serotonin modulators (such as vortioxetine) that target the postsynaptic serotonin receptors rather than the reuptake of serotonin in the synapse. These medications were approved for use in the United States in 2013, and results are still coming in on whether they will prove to be as effective as, but with fewer side effects than, other classes of antidepressants.

SNRIs increase both norepinephrine and serotonin levels by blocking their reuptake. They include duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq). These medications also carry with them a number of undesirable side effects including suicidal thoughts or attempts as well as allergic symptoms, gastrointestinal disturbances, weakness, nausea, vomiting, confusion, memory loss, irritability, and panic attacks, among others. Compared to SSRIs, the SNRIs show statistically significant effects in experimental studies, but clinically they seem to hold no advantages. If anything, SNRIs bring a higher risk of adverse reactions than SSRIs.

Antidepressant Medications

TCAs, which derive their name from the fact that they have a three-ring chemical structure, include amitriptyline (Elavil, Endep), desipramine (Norpramin), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). These medications are particularly effective in alleviating depression in people who have some of the more common biological symptoms, such as disturbed appetite and sleep. Although the exact process by which TCAs work remains unclear, we do know that they block the premature reuptake of biogenic amines back into the presynaptic neurons, thus increasing their excitatory effects on the postsynaptic neurons.

The antidepressant effects of MAOIs, such as phenelzine (Nardil) and tranylcypromine (Parnate), prolong the life of serotonin and norepinephrine in the synapse, thereby increasing their actions in the central nervous system. MAOIs are particularly effective in treating chronic depression in people who have not responded to other medications. However, they have serious side effects that can be life-threatening when people taking them are also on allergy medications or ingest foods or beverages such as beer, cheese, and chocolate, all of which are high in a substance called tyramine. As a result, clinicians do not prescribe MAOIs as commonly as other types of antidepressant medications.

Antidepressant medications take time to work, requiring 2 to 6 weeks to take effect. Once the depression has subsided, the clinician will urge the client to remain on the medication for 4 or 5 additional months, and much longer for people with a history of recurrent, severe depressive episodes. It is best for the clinician and client to work together to develop therapeutic programs that include regular visits early in treatment, expanded educational efforts that focus on the medications, and continued monitoring of treatment compliance.

Biological Treatments for Depressive Disorders

Even though these medications can be effective, especially for certain clients, researchers are concerned that studies of antidepressants suffer from the “file drawer problem”—the fact that investigators are likely to file away, and not even submit for publication, studies that fail to establish significant benefits. In one analysis of 74 FDA-registered studies on antidepressants, 31 percent, accounting for 3,349 study participants, were not published. On the other hand, in the published studies, 94 percent of the medication trials reported positive findings. This bias toward publishing only positive results severely limits our ability to evaluate the efficacy of antidepressants because we are seeing only a slice of the actual data.

Adding further complications, some researchers have questioned whether people with less-than-severe depression might experience positive results because of the so-called placebo effect, in which they get better because they expect to get better.

Medication is certainly one route for the clinician to follow in treating individuals with major depressive disorder. However, increasing attention is being given to the possibility that psychotherapy can be equally effective. Psychotherapy also carries fewer risks and adverse side effects than medication use. Over the long term, it could therefore be a better treatment route with more enduring effects than medication. This is possible in part because, through therapy, individuals can work through some of their underlying issues and also learn skills for managing their symptoms that they can continue using on their own.

Bipolar Medications

The traditional treatment for bipolar disorder is lithium carbonate, referred to as lithium, a naturally occurring salt found in small amounts in drinking water that, when used medically, replaces sodium in the body. Clinicians advise people who have frequent manic episodes (two or more a year) to remain on lithium continuously as a preventive measure. The drawback is that, even though lithium is a natural substance in the body, it can have side effects. These include mild central nervous system disturbances, gastrointestinal upsets, and more serious cardiac effects. As a consequence, people who experience manic episodes may be reluctant or even unwilling to take lithium continuously.

From the client’s perspective, lithium can be seen to interfere with the euphoria that can accompany the beginnings of a manic episode. Consequently, people with this disorder who enjoy those pleasurable feelings may resist taking the medication. Unfortunately, by the time their euphoria escalates into a full-blown episode, it is often too late because their judgment has been clouded by their manic symptoms of grandiosity and elation. To help overcome this dilemma, clinicians may advise their clients to participate in lithium groups, in which members who use the medication on a regular basis provide support to each other

and reinforce the importance of staying on the medication.

Because of the variable nature of bipolar disorder, other medications can be beneficial in treating symptoms apart from the mania itself. For example, people in a depressive episode may need to take an antidepressant medication in addition to the lithium for the duration of the episode. However, this can be problematic for a person who is prone to developing mania, because an antidepressant might provoke hypomania or mania. Those who have psychotic symptoms may benefit from taking antipsychotic medication such as clozapine. People who experience rapid cycling present a challenge for clinicians because of the sudden changes that take place in their emotions and behavior.

Psychopharmacologists report that rapid cyclers, especially those for whom lithium has not been sufficient, seem to respond positively to prescriptions of anticonvulsant medication, such as carbamazepine (Tegretol) or valproate (Depakote), although these alone are not as effective as lithium .

Alternative Biologically Based Treatments

For some clients with mood disorders, medication is either ineffective or slow in alleviating symptoms that are severe and possibly life-threatening. Even with the best treatment, between 60 and 70 percent of individuals with major depressive disorder do not achieve symptom relief. A combination of genetic, physiological, and environmental factors govern the response to medication. Researchers hope to improve the efficacy of medications through pharmacogenetics, the use of genetic testing to identify who will improve with a particular medication, including antidepressants and lithium.

Clinicians, at present, have several somatic alternatives to medication for treatment-resistant depression. One alternative is electroconvulsive therapy (ECT). Clinicians and clients are not sure exactly how ECT works, but most current hypotheses center on ECT-induced changes in neurotransmitter receptors and in the body’s natural opiates which, in turn, cause structural changes in the brain. Deep brain stimulation (DBS) is another somatic treatment clinicians use to target major depressive disorder (as well as obsessive-compulsive disorder and movement disorders).

Based on the hypothesis that at least some mood disorders reflect a disruption in daily biological clocks known as circadian rhythms, researchers are proposing the use of treatments that “reset” the individual’s bodily clock. Such treatments include light therapy, in which the individual is seated in front of a bright light for a period of time, such as 30 minutes in the morning. One distinct advantage of light therapy is that its side effects are minimal and almost entirely disappear after the dosage is reduced or treatment discontinued. Researchers also believe lithium may work on at least some individuals with bipolar disorder by resetting their circadian rhythms.

Psychodynamic Approaches to Treatment

Early psychoanalytic theories based on the psychodynamic approach proposed that people with depressive disorders had suffered a loss early in their lives that affected them at a deep, intrapsychic level. It was attachment theory, however, that focused attention on people’s feelings of security or insecurity arising from the way their caregivers reared them in childhood. Bowlby proposed that people with an insecure attachment style have a greater risk for developing a depressive disorder in adulthood. Following up on Bowlby’s ideas, Bemporad proposed that insecurely attached children become preoccupied with the need to be loved by others. As adults, they form relationships in which they overvalue the support of their

partners. When such relationships end, they become overwhelmed with feelings of inadequacy and loss.

Psychoanalytic explanations of bipolar disorder propose that manic episodes are defensive responses through which individuals stave off feelings of inadequacy, loss, and helplessness. Clients are thought to develop feelings of grandiosity and elation or become hyperenergetic as an unconscious defense against sinking into a state of gloom and despair. Supporting this interpretation, researchers report a positive relationship between use of denial and narcissistic defense mechanisms and the extent of manic symptoms.

Contemporary approaches to treatment within the psychodynamic perspective focus on helping individuals manage their symptoms rather than attempting to repair the core of the individual’s disturbed attachment. These approaches consist of short (8- or 10-session), focused treatments. A review of eight studies comparing short-term psychodynamic therapy to other methods showed this method to be as least as effective as CBT in the treatment of major depressive disorder.

Behavioral and Cognitive Behavioral Approaches

One of the earliest behavioral formulations of theories of depression regards the symptoms of depression as resulting from lack of positive reinforcement. According to this view, depressed people withdraw from life because they no longer have incentives to be active. Contemporary behaviorists base their approach on Lewinsohn’s model. Lewinsohn maintained that depressed people have a low rate of what he termed “response contingent positive reinforcement behaviors,” which increase in frequency as the result of performing actions that produce pleasure. According to the behaviorist point of view, the lack of positive reinforcement elicits the symptoms of low self-esteem, guilt, and pessimism.

In the method known as behavioral activation for depression, based on these behaviorist principles, the clinician helps the client identify activities associated with positive mood. The client keeps a record of the frequency of engaging in these rewarding activities and sets small weekly goals that gradually increase in frequency and duration. These activities are preferably consistent with the client’s core values. Some clients may prefer to explore the arts, whereas others spend time in physical activity. Behavioral activation seems

particularly well suited for clients who are not “psychologically minded,” for group therapy, and for settings such as hospitals, nursing homes, and substance-abuse treatment centers.

Behavioral and Cognitive Behavioral Approaches

Clinicians are increasingly integrating behavioral with cognitive approaches that focus on the role of dysfunctional thoughts as causes of, or at least contributors to, mood disorders. People with depressive disorders, according to the cognitive-behavioral perspective, think in repetitively negative ways that perpetuate their negative emotions.

Beck defined these depressive thoughts as the cognitive triad—that is, a negative view of the self, the world, and the future.

These negative views lead depressed individuals, in turn, to experience a profound

loss of self-esteem, convinced they will never have what they need to feel good

about themselves. They assume they are worthless and helpless and that their

efforts to improve their lives are doomed to fail. In the course of their daily

experiences, the depressed, in this perspective, make faulty interpretations that

keep alive the cycle of negative thoughts and emotions. Each of these faulty

interpretations, or cognitive distortions, has its own unique qualities, but theyshare

a failure to draw logical conclusions from the individual’s experiences.

Examples of Cognitive Distortions Type of Distortion Definition Example

Overgeneralizing If it’s true in one case, it applies to any case that is even slightly similar.

Using selective abstraction Taking seriously only events that represent failures, deprivation, loss, or frustration.

Taking excessive responsibility Feeling responsible for all bad things that happen to you or to others to whom you are close.

Assuming temporal causality Assuming that if it has been true in the past, it’s always going to be true.

Making excessive self-references Feeling at the center of everyone else’s attention and assuming everyone can see your flaws and errors.

Catastrophizing Always thinking the worst and being certain that it will happen.

Engaging in dichotomous thinking Seeing everything as either one extreme or another rather than as mixed or in between.

“I failed my first English exam, so I’m probably going to fail all of them.”

“Even though I won the election for the student senate, I’m not really popular because not everyone voted for me.”

“It’s my fault that my friend didn’t get the internship—I should’ve warned her about how hard the interview would be.”

“My last date was a wipeout, my next date will probably hate me too.”

“When I tripped over the branch in the sidewalk, everyone could see how clumsy I am.”

“Because I failed my accounting exam, I will never make it in the business world.”

“I can’t stand people who are liars because I can never trust them.”

Activity prompt:

Look at the chart on slide 24 and choose two types of cognitive distortions. Create a thread on Blackboard, list the types, and come up with one example for each type.

Behavioral and Cognitive Behavioral Approaches

Behavioral therapy with clients who have depressive disorders follows the general principles that we outlined in the lecture “Theoretical Perspectives” in which clinicians help their clients develop more positively reinforcing experiences. In this approach, clinicians begin with a careful assessment of the frequency, quality, and range of activities and social interactions in their client’s life, focusing on sources of positive and negative reinforcement. Based on this analysis, the clinicians work with their clients to institute changes in their environments while also teaching them social skills to improve the quality and number of their positive interactions. An important focus of the work done by behaviorally oriented clinicians is to encourage clients to increase their participation in activities they find inherently rewarding. These rewarding activities, in turn, can help boost the client’s mood.

Behaviorally oriented clinicians also believe that education is an essential component of therapy. They regard individuals with depressive disorders as perpetuating their negative emotions by setting unrealistic goals, which they are then unable to achieve. To counteract these, clinicians working in the behavioral perspective assign homework exercises that encourage clients to make gradual behavioral changes, which will increase the probability that they can achieve their goals and thus feel rewarded.

Another technique used by the behavioral clinician combines behavioral contracting with self-reinforcement. For example, the clinician and client may agree that a client would benefit from the opportunity to socialize outside the home more often. Together, they would then set up a schedule of rewards in which they pair the social activity with something the client identifies as a desirable reward compatible with the goals of treatment (the clinician would not recommend that the client use the rewards of alcohol, drugs, or online gambling). Other methods the behaviorally oriented clinician would use include more extensive instruction, modeling, coaching, role playing, rehearsal, and perhaps working with the client in a real-world setting.

Behavioral and Cognitive Behavioral Approaches

The focus of cognitive-behavioral therapy (CBT) is on helping clients try to change their dysfunctional thought processes that in turn will improve their mood. Like behaviorally oriented therapy, CBT requires an active collaboration between the client and the clinician. In contrast to behaviorally oriented therapy, however, CBT also focuses on the client’s dysfunctional thoughts and how to modify them through cognitive restructuring.

Mindfulness training, as an additional component of a cognitive-behavioral intervention, can help clients develop a greater sense of self-efficacy, an added boost to its positive effects on mood. Another CBT technique known as mood monitoring can further help clients learn ways to track their mood over time and look for patterns in mood fluctuation. This is particularly helpful in the case of clients with bipolar disorder, who through the mood monitoring technique become more self-aware of when their symptoms might be worsening, so they can intervene using skills or other methods to avoid a full-blown manic or depressive episode.

Clinicians treating people with bipolar disorder customarily turn first to pharmacological interventions. However, psychological interventions can be beneficial in helping clients develop better coping strategies in an effort to minimize the likelihood of relapse. As we mentioned earlier, people who have experienced a manic episode may be tempted to forgo taking their medication because they wish to re-experience the exciting highs of a manic episode. If they can develop insight into the risks of noncompliance, however, and gain an improved understanding of medications such as lithium, they are more likely to adhere to the treatment program.

Psychoeducation is an especially important aspect of treating people with bipolar disorder to help them understand its nature, as well as the reasons medication is so important in controlling symptoms. Moreover, CBT can also be an effective intervention for clients with bipolar disorder to help them cope with the periods in which their symptoms are beginning to emerge but are not yet full-blown. Rather than using one therapeutic approach, then, clinicians currently recommend the use of a combination of methods ranging from traditional psychotherapeutic medications to mindfulness training, and even nutritional supplements and hormone therapy. They are also now turning to cognitive remediation therapy, based on the findings in the literature of cognitive abnormalities in memory, inhibitory control, and attention.

Interpersonal Approaches

Developed as a brief intervention, interpersonal therapy (IPT) is a focused approach intended to last between 12 and 16 weeks. In IPT, clients are helped to manage the interpersonal stress associated with their depressive episodes, which themselves are seen as a function of genetic predisposition. Administered according to a set of guidelines, interpersonal therapy provides clinicians with a clear model to follow so that treatment can proceed within the scheduled time frame. The IPT manual has the additional advantage of ensuring some consistency across therapists, making it possible to evaluate its effectiveness empirically.

Clinicians administer interpersonal therapy in three broad phases. In the first phase, the clinician assesses the magnitude and nature of the individual’s depression using quantitative assessment measures and semistructured interviews. Depending on the type of depressive symptoms the individual shows, the therapist may consider combining treatment with antidepressant medications along with psychotherapy. In the second phase, the therapist and the client collaborate on formulating a treatment plan that focuses on the primary problem. Typically, these problems are related to grief, interpersonal disputes, role

transitions, and problems in interpersonal relationships stemming from inadequate social skills. The therapist then carries out the treatment plan in the third phase, varying the methods according to the precise nature of the client’s primary problem. The IPT approach encourages clinicians to combine such techniques as encouraging self-exploration, providing support, educating the client on the nature of depression, and offering feedback on the client’s ineffective social skills. A primary focus of therapy is on the here and now, rather than on past childhood or developmental issues.

For clients who cannot take antidepressant medications or for whom it is impractical to use medications, IPT is an especially valuable intervention in that non-medical staff can administer it, or clients, with instruction, can learn it themselves. A large-scale analysis of studies conducted over 30 years showed that interpersonal therapy was significantly more effective than cognitive-behavioral therapy or medications.

Interpersonal Approaches

Interpersonal and social rhythm therapy (IPSRT) is a biopsychosocial approach to treating people with bipolar disorder that incorporates the concepts of stressful life events and disturbances in circadian rhythms (such as altered sleep/wake cycles, appetite, and energy level) into a focus on the individual’s personal relationships. According to the IPSRT model, mood episodes are likely to emerge from medication nonadherence, stressful life events, and disruptions in social rhythms.

Clinicians who use IPSRT focus on educating clients about medication adherence, giving them a forum to explore their feelings about the disorder, and helping them develop insight about the ways in which the disorder has altered their lives. Clients learn to pay careful attention to the regularity of daily routines (including the timing of events and the stimulation that occurs with these events), and the extent to which life events, positive as well as negative, influence daily routines. The goal of IPSRT is to increase the stability of a client’s social rhythms.

Reducing interpersonal stress for clients with bipolar disorder is important for several reasons. First, stressful life events heighten the arousal of the individual’s autonomic nervous system and hence alter circadian rhythms. Helping clients cope with stress helps adjust these rhythms. Second, many life events, whether perceived as stressful or not, themselves cause changes in daily routines that in turn create more stress. Third, major life stressors affect a person’s mood and also lead to significant changes in social routines. As clients stabilize their social rhythms and routines while improving their interpersonal relationships, their stress levels decline accordingly. Researchers employing IPSRT support its use on an outpatient and inpatient basis. However, in comparing IPT with IPSRT, a randomized clinical treatment study showed that the two were equally

effective.

Looking across the results of virtually all published studies on interventions for mood disorders, Hollon and Ponniah concluded that cognitive-behavioral and behavioral therapy meet the criteria for evidence-based treatments, receiving strong support particularly for individuals with less severe or chronic depression. A review of randomized clinical trials comparing CBT with IPT shows both to be equally effective in treating major depressive disorder for at least 1 year post-treatment. Individuals with more severe depressive or bipolar disorders also benefit from cognitive-behavioral, interpersonal, and behaviorally oriented therapy above and beyond the effects of medication, and perhaps even instead of medication entirely, particularly over the long term.

Sociocultural Perspectives

According to the sociocultural perspective, individuals develop depressive disorders in response to external life circumstances. These circumstances can be specific events such as sexual victimization, chronic stress such as poverty and single parenting, or episodic stress such as bereavement or job loss. Women are more likely to be exposed to these stressors than are men, a fact that may account, at least in part, for the higher frequency in the diagnosis of depressive disorders in women.

However, acute and chronic stressors seem to play a differential role in predisposing an individual to experiencing depressive symptoms. Exposure to an acute stress such as the death of a loved one or an automobile accident could precipitate a major depressive episode. However, exposure to chronic strains from poor working conditions, health or interpersonal problems, or financial adversity can interact with genetic predisposition and personality to lead certain individuals to experience more persistent feelings of hopelessness. Moreover, once activated, an individual’s feelings of depression and hopelessness can exacerbate the effects of exposure to stressful environments, which, in turn, can further increase the individual’s feelings of chronic strain.

On the positive side, strong religious beliefs and spirituality may combine with the social support that membership in a religious community provides to lower an individual’s chances of developing depression, even among those with high risk. Among the adult children of individuals with major depressive disorder, those with the strongest religious beliefs were less likely to experience a recurrence over a 10-year period.

Suicide

Although not a diagnosable disorder, suicidality is one potential diagnostic feature of a major depressive episode. The definition of suicide is “a fatal self-inflicted destructive act with explicit or inferred intent to die”. Suicidal behavior runs along a continuum of thinking about ending one’s life (“suicidal ideation”), to developing a plan, to undertaking nonfatal suicidal behavior (“suicide attempt”), to actually ending one’s life (“suicide”).

The highest suicide rates by age are for people 45 to 54 years old (20.3 per 100,000). Individuals 85 and older have the next highest rates (19.4) as well as the highest rates of suicide by discharge of firearms (13.7). Within the United States, white men are much more likely than are non-white men to commit suicide.

Around the world, there are approximately 1 million suicides each year. The highest global suicide rates are for males in Lithuania (61.3 per 100,000) and for females in South Korea (22.1 per 100,000), and the lowest rates (near 0) for several Latin American and Caribbean countries, Jordan, and Iran.

Young adults are at highest risk of suicide in many countries outside the United States. In Europe and North America, depression and alcohol-use disorders are major psychological risk factors for suicide. In the United States, more than 90 percent of suicides occur in people with a psychological disorder. In contrast, impulsiveness plays a higher role in the suicides of people from Asian countries

Suicide

The buffering hypothesis of suicidality describes resilience as a separate dimension from risk. You may be at risk of committing suicide, but if you are high on resilience, you are unlikely to do so. The statistically higher risk you may face due to living in a stressful environment may not translate into higher suicidality if you feel you can cope successfully with these circumstances.

The factors that seem to contribute to high resilience include the ability to make positive assessments of your life circumstances and to feel in control over these circumstances. Additional buffers to suicide risk are a number of psychosocial factors such as being able to solve problems, having high self-esteem, feeling supported by family and significant others, and being securely attached. People who do not believe suicide is an acceptable option to stress are also better able to overcome high risk. On the negative side, low resilience occurs with high levels of perfectionism and hopelessness. Having friends or family members who attempted suicide represents another risk factor.

Interventions based on the resilience model would not only address the individual’s specific risk factors, then, but also assess and then strengthen the individual’s feelings of personal control and perceived abilities to handle stress. CBT is one such intervention shown to be effective on reducing suicide attempts in populations such as adolescents and members of the military with a history of suicide attempts.

Suicide

The Biopsychosocial Perspective

The biopsychosocial perspective is particularly appropriate for understanding why people commit suicide and in many ways parallels the understanding gleaned from an integrative framework for major depressive disorders.

Biological theories emphasize the genetic and physiological contributions that also contribute to the causes of mood disorders.

Psychological theories focus on distorted cognitive processes and extreme feelings of hopelessness that characterize suicide victims.

From a sociocultural perspective, the variations between and within countries suggest contributions relating to an individual’s religious beliefs and values and the degree to which the individual is exposed to life stresses.

The perspective of positive psychology provides a framework for understanding why individuals who are at high risk for the reasons above nevertheless do not commit suicide.

Depressive and Bipolar Disorders: The Biopsychosocial Perspective

The disorders we covered in this lecture span a range of phenomena, from chronic but distressing sad moods to rapidly vacillating alternations between mania and depression. Although these disorders clearly indicate disturbances in neurotransmitter functioning, they also reflect the influences of cognitive processes and sociocultural factors.

Because individuals may experience the symptoms of depressive disorders for many years, clinicians are increasingly turning to nonpharmacological interventions, particularly for cases in which individuals have mild or moderate symptoms. The situation for clients with bipolar disorder is more complicated, because lifelong maintenance therapy on medication is more likely necessary. Nevertheless, these individuals can benefit from psychological interventions to help keep their symptoms monitored and under control.

Even individuals whose mood disorder symptoms reflect a heavy influence of biology, however, should have access to a range of therapeutic services. With the development of evidence-based approaches, which integrate interventions across the individual’s multiple domains of functioning, the chances are good that people with these disorders will increasingly have the ability to obtain treatment that allows them to regulate their moods and lead more fulfilling lives.

Sources

Image 1: https://www.verywellmind.com/common-types-of-depression-1067313

Image 2: https://medium.com/@jenniferschmidtwrites/the-truth-about-mdd-e820d30d1c9f Image 3: Text, page 173

Image 4: http://neurowiki2013.wikidot.com/individual:cyclothymia

Image 5: https://www.portstluciehospitalinc.com/bipolar-disorder-symptoms-causes-and-treatment/ Image 6: https://www.northpointwashington.com/co-occurring/cyclothymic-disorder.php Image 7: https://www.tutor2u.net/psychology/reference/explaining-depression-becks-cognitive-triad

Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education.