Chapter 8 Flashcards
An OVerVIew Of DePreSSIOn AnD MAnIA
The disorders described in this chapter used to be categorized under several different general labels, such as “depressive disor- ders,” “affective disorders,” or even “depressive neuroses.” Tradi- tionally, these problems have been grouped under the heading mood disorders because they are characterized by severe devia- tions in mood. In DSM-5, these various mood disorders are grouped in two adjacent chapters: depressive disorders, and bipo- lar and related disorders.
The fundamental experiences of depression and mania contrib- ute, either singly or together, to all the mood disorders. We describe each state and discuss its contributions to the various mood disorders. Then we briefly describe the additional defining criteria, features, or symptoms that define the specific disorders.
The most commonly diagnosed and most severe depression is called a major depressive episode. DSM-5 criteria, items A to C listed under major depressive disorder (see DSM Table 8.1), describe it as an extremely depressed mood state that lasts at least two weeks and includes cognitive symptoms (such as feel- ings of worthlessness and indecisiveness) and disturbed physical functions (such as altered sleeping patterns, significant changes in appetite and weight, or a very notable loss of energy) to the point that even the slightest activity or movement requires an overwhelming effort. The episode is typically accompanied by a marked general loss of interest and of the ability to experience any pleasure from life, including interactions with family or friends and accomplishments at work or at school. (The inability to experience pleasure is termed anhedonia.) Although all symp- toms are important, evidence suggests that the most central indi- cators of a full major depressive episode are the physical changes (sometimes called somatic or vegetative symptoms) (Bech, 2009; Buchwald & Rudick-Davis, 1993; Keller et al., 1995; Kessler & Wang, 2009), along with the behavioural and emotional shut- down, as reflected by low behavioural activation (Dimidjian et al., 2011). The average duration of such an episode if untreated is approximately nine months (Eaton et al., 1997; Tollefson, 1993).
The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or euphoria. In mania, individuals find extreme pleasure in every activity; in fact, some patients compare their daily experience of mania with a continuous orgasm. They become extraordinarily active (hyperac- tive), requiring very little sleep, and may develop grandiose plans, believing they can accomplish anything they desire. The DSM-5 highlights this feature by adding “persistently increased goal- directed activity or energy” to the “A” criterion (see DSM Table 8.2; American Psychiatric Association, 2013). Speech is typically very rapid and may become incoherent, because the individual is attempting to express so many exciting ideas at once; this feature is typically
referred to as flight of ideas.
The DSM-5 criteria for a manic
episode require a duration of only one week, less if the episode is severe enough to require hospitalization. Hospitalization could occur, for example, if the individual was engaging in a self-destructive buying spree, charging thousands of dollars in the expectation of making a million dollars the next day. Irritability is often part of a manic episode, usually near the end. Paradoxically, being anxious or depressed is also commonly part of mania, as described later. The average duration of an untreated manic episode is two to six months (Angst, 2009; Solomon et al., 2010).
The DSM-5 also defines a hypomanic episode, a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning and need last only four days rather than a full week. (Hypo means “below”; thus, the episode is below the level of a manic episode.) A hypomanic episode is not in itself necessarily problematic, but it does contribute to the defi- nition of several mood disorders.
The STruCTure Of MOOD DISOrDerS
Individuals who experience either depression or mania are said to have a unipolar mood disorder, because their mood remains at one “pole” of the depression-mania continuum. Mania by itself (unipolar mania) probably does occur but seems to be rare, because most people with a unipolar mood disorder eventually develop depression. Manic episodes alone may be somewhat more frequent in adolescents, however. Someone who alternates between depression and mania is said to have a bipolar mood disorder, travelling from one pole of the depression–elation continuum to the other and back again. This label is somewhat misleading, however, because depression and elation may not exactly be at opposite ends of the same mood state; in fact, though related, they are often relatively independent. An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time or be depressed with a few symptoms of mania. This episode is characterized as having mixed features. Manic episodes are characterized by dysphoric (anxious or depressive) features more commonly than was thought, and dysphoria can be severe (Cassidy et al., 2008; Swann et al., 2013). In one study, 30 percent of 1090 patients hospitalized for acute mania had mixed episodes (Hantouche et al., 2006). In another carefully constructed study of more than 4000 patients, as many as two-thirds of patients with bipolar depressed episodes also had manic symptoms, most often racing thoughts (flight of ideas), distractibility, and agitation. These patients were also more severely impaired than those without concurrent depression and manic symptoms (Goldberg et al., 2009; Swann et al., 2013). The rare individual who suffers from manic episodes alone can be expected to become depressed later. In general, newer models view bipolar disorder as an evolving condition, proceeding through different at-risk stages with mild symptoms early in the disease progressing to a later chronic disorder (Frank et al., 2015; Kupfer et al., 2015). In the DSM-5, the term “mixed features” requires specifying whether a predominantly manic or predomi- nantly depressive episode is present, and then noting if enough symptoms of the opposite polarity are present to meet the mixed features criteria.
It is important to determine the course or temporal patterning of the depressive or manic episodes. For example, do they tend to recur? If they do, does the patient recover fully for at least two months between episodes (termed “full remission”) or only partially recover retaining some symptoms (“partial remission”)? Do the depressive episodes alternate with manic or hypomanic episodes or not? All these patterns for mood disorders are impor- tant to note, since they contribute to decisions on which diagnosis is appropriate.
The importance of temporal course (patterns of recurrence and remittance) makes the goals of treating mood disorders somewhat different from those for other psychological disorders. Clinicians want to do everything possible to relieve people like Katie of their current depressive episode, but an equally important goal is to prevent future episodes—in other words, to help people like Katie stay well for a longer period.
CliniCal DesCription - DePreSSIVe DISOrDerS
The most easily recognized mood disorder is major depressive disorder, defined by the presence of depression and the absence of manic, or hypomanic, episodes before or during the episode (see DSM Table 8.1). We now know that an occurrence of just one isolated depressive episode in a lifetime is rare (Angst, 2009; Eaton et al., 2008; Kessler & Wang, 2009).
If two or more major depressive episodes occurred and were separated by at least two months during which the individual was not depressed, the major depressive disorder is noted as being recurrent. Recurrence is very important in predicting the future course of the disorder and in choosing appropriate treatments. Individuals with recurrent major depression usually have a family history of depression, unlike people who experience single episodes. As many as 85 percent of single-episode cases later experience a second episode (Angst, 2009; Eaton et al., 2008; Judd, 2000; Souery et al., 2012), based on follow-ups as long as 23 years (Eaton et al., 2008). In the first year following an episode, the risk of recurrence is 20 percent, but it rises as high as 40 percent in the second year (Boland & Keller, 2009). Because of this finding and others reviewed later, clinical scientists have recently concluded that unipolar depression is often a chronic condition that waxes and wanes over time but seldom disappears (Judd, 2012). The median lifetime number of major depressive episodes is four to seven; in one large sample, 25 percent experi- enced six or more episodes (Angst, 2009; Kessler & Wang, 2009). The median duration of recurrent major depressive episodes is four to five months (Boland & Keller, 2009; Kessler et al., 2003), somewhat shorter than the average length of the first episode.
On the basis of these criteria, how would you diagnose Katie? Katie experienced severely depressed mood, feelings of worth- lessness, difficulty concentrating, recurrent thoughts of death, sleep difficulties, and loss of energy. She clearly met the criteria for major depressive disorder, recurrent. Katie’s depressive episodes were quite severe when they occurred, but she tended to cycle in and out of them.
Persistent depressive disorder (dysthymia) shares many of the symptoms of major depressive disorder but differs in its course. There may be fewer symptoms (as few as two; see DSM Table 8.3) but depression remains relatively unchanged over long periods, sometimes 20 or 30 years or more (Angst, 2009; Cristancho et al., 2012; Klein, 2008; Klein et al., 2000, 2006; Murphy & Byrne, 2012).
Persistent depressive disorder is defined as depressed mood that continues at least two years, during which the patient cannot be symptom free for more than two months at a time even though they may not experience all of the symptoms of a major depres- sive episode. It identifies patients who were formerly diagnosed with dysthymic disorder and other depressive disorders (Rhebergen & Graham, 2014). Persistent depressive disorder differs from a major depressive disorder in the number of symp- toms required, but mostly in the chronicity. It is considered more severe, since patients with persistent depression present with higher rates of comorbidity with other mental disorders, are less responsive to treatment, and show a slower rate of improvement over time. In a 10-year prospective follow-up study, Klein and colleagues (2006) suggest that chronicity (versus nonchronicity) is the most important distinction in diagnosing depression independent of whether the symptom presentation meets criteria for a major depressive disorder (as just noted), because these two groups (chronic and nonchronic) seem different not only in course over time but also in family history and cognitive style. About 20 percent of patients with a major depressive episode report chronicity of this episode for at least two years, thereby meeting criteria for persistent depressive disorder (Klein, 2010).Also, 22 percent of people suffering from persistent depres- sion with fewer symptoms (specified as “with pure dysthymic syndrome”) eventually experienced a major depressive episode (Klein et al., 2006). These individuals, who suffer from both major depression episodes and persistent depression with fewer symptoms, are said to have double depression. Typically, a few depressive symptoms develop first, perhaps at an early age, and then one or more major depressive episodes occur later, only to revert to the underlying pattern of depression once the major depressive episode has run its course (Boland & Keller, 2009; Klein et al., 2006; Rubio et al., 2011). Identifying this particu- lar pattern is important because it is associated with higher severity and a problematic future course (Boland & Keller, 2009; Klein et al., 2006). For example, Klein et al. (2006) found that the relapse rate of depression among people meeting criteria for DSM-IV dysthymia was 71 percent. Consider the case of Jack.
Persistent depressive disorder is further specified depending on whether or not a major depressive episode is part of the picture. Thus, one might meet criteria for the disorder “with pure dysthymic syndrome,” meaning one has not met criteria for a major depressive episode in at least the preceding two years, “with persistent major depressive episode,” indicating the pres- ence of a major depressive episode over at least a two-year period, or “with intermittent major depressive episodes,” which is the double depression that Jack suffered from. In these cases, it is important to note whether or not the patient is currently in a major depressive episode. For both major depressive disorder and persistent depressive disorder, a depiction of the various course configurations of depression can be seen in ■ Figure 8.1.
Additional Defining Criteria for Depressive Disorders
Look again at DSM Table 8.1 on the diagnostic criteria for major depressive disorder; notice the section at the bottom that asks the clinician to specify the features of the latest depressive episode. These instructions are here because these symptoms, or specifiers, may or may not accompany a depressive disorder; when they do, they are often helpful in determining the most effective treatment or likely course.
In addition to rating the severity of the episode as mild, moder- ate, or severe, clinicians use eight basic specifiers to describe depressive disorders. These are (1) with psychotic features (mood- congruent or mood-incongruent), (2) with anxious distress (mild to severe), (3) with mixed features, (4) with melancholic features, (5) with atypical features, (6) with catatonic features, (7) with peripartum onset, and (8) with seasonal pattern. Some of these specifiers apply only to major depressive disorder. Others apply to both major depressive disorder and persistent depressive disor- der. Three are described briefly below.
Psychotic features specifiers. Some individuals in the midst of a major depressive (or manic) episode may experience psychotic symptoms, specifically hallucinations (seeing or hearing things that aren’t there) and delusions (strongly held but inaccurate beliefs) (Rothschild, 2013). Patients may also have somatic (physical) delusions, believing, for example, that their bodies are rotting internally and deteriorating into nothingness. Some may hear voices telling them how evil and sinful they are (auditory hallucinations). Such hallucinations and delusions are called mood congruent, because they seem directly related to the depres- sion. On rare occasions, depressed individuals might have other types of hallucinations or delusions such as delusions of grandeur (believing, for example, they are supernatural or supremely gifted) that do not seem consistent with the depressed mood. This is a mood-incongruent hallucination or delusion. Although quite rare, this condition signifies a serious type of depressive episode that may progress to schizophrenia (or may be a symptom of schizophrenia to begin with). Delusions of grandeur accompany- ing a manic episode are mood congruent. Conditions in which psychotic symptoms accompany depressive episodes are rela- tively rare, occurring in 5 to 20 percent of identified cases of depression (Flores & Schatzberg, 2006; Ohayon & Schatzberg, 2002). Psychotic features in general are associated with a poor response to treatment, greater impairment, and fewer weeks with minimal symptoms, compared with nonpsychotic depressed patients over a 10-year period (Busatto, 2013; Flint et al., 2006).
Peripartum onset specifier. Peri means “surrounding”—in this case, the period of time just before and just after giving birth. This specifier can apply to both major depressive and manic episodes. Between 13 and 19 percent of all women giving birth (one in eight) meet criteria for a diagnosis of depression, referred to as peripartum depression. In one study, 7 percent met criteria for a full major depressive episode (Gavin et al., 2005). Typically, a somewhat higher incidence of depression is found postpartum (after the birth) than during pregnancy itself (Viguera et al.,
2011). In another recent important study, 14 percent of 10000 women who gave birth screened positively for depression and fully 19 percent of those depressed new mothers had serious thoughts of harming themselves (Wisner et al., 2013). During the peripartum period (pregnancy and the six-month period immedi- ately following childbirth), early recognition of possible psychotic depressive (or manic) episodes is important, because in a few tragic cases a mother in the midst of an episode has killed her newborn child (Purdy & Frank, 1993; Sit et al., 2006). Fathers don’t entirely escape the emotional consequences of birth. Ramchandani and colleagues (2005) followed 11833 mothers and 8431 fathers for eight weeks after the birth of their child. Of the mothers, 10 percent showed a marked increase in depressive symptoms on a rating scale, but so did 4 percent of the fathers. If you extend the period from the first trimester to one year after birth, the rate of depression is approximately 10 percent for fathers and as high as 40 percent for mothers. And depression in fathers was associated with adverse emotional and behavioural outcomes in children 3.5 years later (Paulson & Bazemore, 2010).
More minor reactions in adjustment to childbirth—called the “baby blues”—typically last a few days and occur in 40 to 80 percent of women between one and five days after delivery. During this period, new mothers may be tearful and have some temporary mood swings, but these are normal responses to the stresses of childbirth and disappear quickly; the peripartum onset specifier does not apply to them (O’Hara & McCabe, 2013; Wisner et al., 2010). However, in peripartum depression, most people, including the new mother herself, have difficulty under- standing why she is depressed, because they assume this is a joyous time. Many people forget that extreme stress can be brought on by physical exhaustion, new schedules, adjustment to nursing, sleep deprivation, and other changes that follow the birth. There is also some evidence that women with a history of peripartum depression meeting full criteria for an episode of major depression may be affected differently by the rapid decline in reproductive hormones that occurs after delivery (Wisner et al., 2002; Workman et al., 2012) or may have elevated corticotrophin- releasing hormone in the placenta (Meltzer-Brody et al., 2011; Yim et al., 2009) and that these factors may contribute to peripar- tum depression. But these findings need replication, because all women experience very substantial shifts in hormone levels after delivery, but only some develop a depressive disorder. Nor is there strong evidence that hormonal levels are significantly different in peripartum depressed and nondepressed women (Workman et al., 2012). A close examination of women with peripartum depression revealed no essential differences between the characteristics of this mood disorder and others (O’Hara & McCabe, 2013; Wisner et al., 2002). Therefore, peripartum depression did not require a separate category in the DSM-5 and is simply a specifier for a depressive disorder. (Approaches to treatment for peripartum depression do not differ from those for non-peripartum depression.)
Seasonal pattern specifier. This temporal specifier applies to recurrent major depressive disorder (and also to bipolar disor- ders). It accompanies episodes that occur during certain seasons (e.g., winter depression). The most usual pattern is a depressive episode that begins in the late fall and ends with the beginning of spring. (In bipolar disorder, individuals may become depressed during the winter and manic during the summer.) These episodes must have occurred for at least two years with no evidence of nonseasonal major depressive episodes occurring during that period of time. This condition is called seasonal affective disorder (SAD).
Although some studies have reported seasonal cycling of manic episodes, the overwhelming majority of seasonal mood disorders involve winter depression, which has been estimated to affect as many as 3 percent of North Americans (Lam et al., 2006; Levitt & Boyle, 2002). But fully 15 to 25 percent of the popula- tion might have some vulnerability to seasonal cycling of mood that does not reach criteria for a disorder (Kessler & Wang, 2009; Sohn & Lam, 2005). Unlike more severe melancholic types of depression, people with winter depressions tend toward excessive sleep (rather than decreased sleep) and increased appetite and weight gain (rather than decreased appetite and weight loss), symptoms shared with atypical depressive episodes. Although SAD seems a bit different from other major depressive episodes, family studies have not yet revealed any significant differences that would suggest winter depressions are a separate type (Lam & Lavitan, 2000).
onset anD Duration - depressive disorders
The mean age of onset for major depressive disorder is 25 years in community samples who are not in treatment (Burke et al., 1990) and 29 years for patients who are in treatment (Judd et al., 1998a), but the average age of onset seems to be decreasing (Kessler et al., 2003; Weissman et al., 1991). In fact, the preva- lence of major depression increases dramatically during the adolescent years (e.g., Offord et al., 1987), particularly in adoles- cent girls (Georgiades et al., 2006; see also review in Santor & Kusumakar, 2001). In 1989, a survey of people in five different American cities (Klerman & Weissman, 1989; Wickramaratne et al., 1989) revealed a greatly increased risk of developing depression in younger people. Among those born before 1905, only 1 percent had developed depression by age 75; of those born since 1955, 6 percent had become depressed by age 24. A later study based on very similar surveys conducted in Canada, Puerto Rico, Italy, Germany, France, Taiwan, Lebanon, and New Zealand suggests that this trend toward developing depression at increas- ingly earlier ages is occurring worldwide (Cross-National Collaborative Group, 1992).
As we noted previously, the length of depressive episodes is variable, with some lasting as little as two weeks; in more severe cases, an episode might last for several years, with the average duration of the first episode being two to nine months if untreated (Angst, 2009; Boland & Keller, 2009). Although nine months is a long time to suffer with a severe depressive episode, evidence indicates that even in the most severe cases, the probability of remission of the episode within one year approaches 90 percent (Kessler & Wang, 2009). In those severe cases in which the episode lasts five years or longer, 38 percent can be expected to eventually recover (Mueller et al., 1996). Occasionally, however, episodes may not entirely clear up, leaving some residual symp- toms. In this case, the likelihood of a subsequent episode with another incomplete recovery is much higher (Boland & Keller, 2009; Judd, 2012). Awareness of this increased likelihood is important to treatment planning, because treatment should be continued much longer in these cases.
Investigators have found a lower (0.07 percent) prevalence of persistent mild depressive symptoms in children compared with adults (3 to 6 percent) (Klein et al., 2000), but symptoms tend to be stable throughout childhood (Garber, Gallerani, & Frankel, 2009). Kovacs, Akiskal, Gatsonis, and Parrone (1994) found that 76 percent of a sample of children with persistent mild depressive symptoms later developed major depressive disorder.
Persistent depressive disorder may last 20 to 30 years or more, although a preliminary study reported a median duration of approximately five years in adults (Klein et al., 2006) and four years in children (Kovacs et al., 1994). Klein and colleagues (2006) conducted a 10-year follow-up of 97 adults with DSM-IV dysthymia and found that 74 percent had recovered at some point, but 71 percent of those had relapsed. The whole sample of 97 patients spent approximately 60 percent of the 10-year follow- up period meeting full criteria for a mood disorder. This compares with 21 percent of a group of patients with major depressive disorder also followed for 10 years. Even worse, patients with persistent depressive disorder with less severe depressive symp- toms (dysthymia) were more likely to attempt suicide than a comparison group with (nonpersistent) episodes of major depres- sive disorder during a five-year period.
From GrieF to Depression
At the beginning of the chapter, we asked if you had ever felt down or depressed. Almost everyone has. But if someone you love has died—particularly if the death was unexpected and the person was a member of your immediate family—you may, after your initial reaction to the trauma, have experienced a number of depressive symptoms, as well as anxiety, emotional numb- ness, and denial (Kendler et al., 2008; Shear, 2012; Shear et al., 2011; Simon, 2012). Sometimes individuals experience very severe symptoms requiring immediate treatment such as a full major depressive episode, perhaps with psychotic features, suicidal ideation, or severe weight loss and so little energy that the individual cannot function (Maciejewski et al., 2007). We must confront death and process it emotionally. All religions and cultures have rituals, such as funerals and burial ceremonies, to help us work through our losses with the support and love of our relatives and friends. Usually, the natural grieving process resolves within the first several months, although some people grieve for a year or longer (Currier et al., 2008; Maciejew- ski et al., 2007). The acute grief most of us feel eventually evolves into what is called integrated grief, in which the final- ity of death and its consequences are acknowledged and the individual adjusts to the loss. New, bittersweet, but mostly posi- tive memories of the deceased person that are no longer domi- nating or interfering with functioning are then incorporated into memory (Shear et al., 2011).
Integrated grief often recurs at significant anniversaries, such as the birthday of the loved one, holidays, and other meaningful occasions, including the anniversary of the death. This is all a very normal and positive reaction. In fact, mental health profes- sionals are concerned when someone does not grieve after a death, because grieving is our natural way of confronting and handling loss.
When grief lasts beyond the typical time, mental health professionals become concerned (Neimeyer & Currier, 2009). After six months to a year or so, the chance of recovering from severe grief without treatment is considerably reduced and, for approximately 7 percent of bereaved individuals (Kersting et al., 2011; Shear et al., 2011), a normal process becomes a disorder. At this stage, suicidal thoughts increase substantially and focus mostly on joining the beloved deceased (Stroebe et al., 2005).
The ability to imagine events in the future is generally impaired, because it is difficult to think of a future without the deceased (MacCallum & Bryant, 2011; Robinaugh & McNally, 2013). Individuals also have difficulty regulating their own emotions, which tend to become rigid and inflexible (Gupta & Bonanno, 2011). Many of the psychological and social factors related to mood disorders in general, including a history of past depressive episodes, also predict the development of what is called the syndrome of complicated grief, although this reaction can develop without a preexisting depressed state (Bonanno et al., 2004).
A longitudinal study by a group including researchers at the University of British Columbia (Bonanno et al., 2002) showed that pre-loss dependency was predictive of a pathological grief reaction following the loss of a spouse. Particularly prominent symptoms of a pathological grief reaction include intrusive memories and distressingly strong yearnings for the loved one and avoiding people or places that are reminders of the loved one. In cases of complicated grief, the rituals intended to help us face and accept death were ineffective. As with victims who have post-traumatic stress, one therapeutic approach is to help griev- ing individuals re-experience the trauma under close supervision (Shear, 2010). Usually the grieving person is encouraged to talk about the loved one, the death, and the meaning of the loss while experiencing all the associated emotions, until he or she can come to terms with reality. This would include finding some meaning in the traumatic loss, incorporating positive emotions associated with memories of the relationship into the intense negative emotions connected with the loss, and arriving at the position that the person can cope with the pain and life will go on, thereby achieving a state of integrated grief (Bonanno & Kaltman, 1999).
Some researchers have cautioned against treating pathological grief reaction and depression in the same manner. For example, at the University of British Columbia, John Ogrodniczuk and his colleagues (2003) showed that dimensions of pathological grief could be distinguished from dimensions of depression among close to 400 psychiatric outpatients who had experienced one or more significant losses. And it was the grief dimensions that showed the most improvement in group therapy specifically designed to treat pathological grief reaction.
other Depressive DisorDers
Premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder, both depressive disorders, were added to the DSM-5.
Premenstrual Dysphoric Disorder (PMDD)
The history of the development of PMDD over the last several decades as a diagnosis was described in some detail in Chapter 3. Clinicians identified a small group of women, from 2 to 5 percent, who experienced severe and sometimes incapaci- tating emotional reactions during the premenstrual time (Epperson et al., 2012). But strong objections to making this condition an official diagnosis were based on concerns that women who were experiencing a very normal monthly physio- logical cycle, as part of being female, would now be classified as having a disorder, which would be very stigmatizing. It has now been clearly established that this small group of women differs in a number of ways from the 20 to 40 percent of women who experience uncomfortable premenstrual symptoms (PMS) that, nevertheless, are not associated with impairment of functioning. Criteria defining PMDD are presented in DSM Table 8.4. As you can see, a combination of physical symptoms, severe mood swings, and anxiety is associated with incapacitation during this time (Hartlage et al., 2012). All the evidence indicates that PMDD is best considered a disorder of mood as opposed to a physical disorder (such as an endocrine disorder), and, as pointed out in Chapter 3, the creation of this diagnostic category should greatly help the thousands of women coping with this disorder receive the treatment they need to relieve their suffering and improve their functioning.
Disruptive Mood Dysregulation Disorder
Children and adolescents have been diagnosed with bipolar disorder at greatly increasing rates over the last several years. In fact, from 1995 to 2005 the diagnosis of bipolar disorder in children increased 40-fold overall and has quadrupled in U.S. community hospitals (up to 40 percent) (Leibenluft & Rich, 2008; Moreno et al., 2007). Why the increase? Many clinicians are now using much broader diagnostic criteria that would not correspond to current definitions of bipolar I or bipolar II disor- der but rather fall under the relatively vague category of bipolar disorder not otherwise specified, and include children with chronic irritability, anger, aggression, hyperarousal, and frequent temper tantrums that are not limited to an occasional episode (as might be the case if the child were cycling into a manic episode since irritability sometimes accompanies discrete manic episodes).
But the most important observation is that these children show no evidence of periods of elevated mood (mania), which has been a requirement for a diagnosis of bipolar disorder (Leibenluft, 2011). Additional research demonstrated that these children with chronic and severe irritability and difficulty regulating their emotions resulting in frequent temper tantrums are at increased risk for additional depressive and anxiety disorders rather than manic episodes, and that there is no evidence of excessive rates of bipolar disorder in their families, which would expect if this condition were truly bipolar disorder. It was also recognized that this severe irritability is more common than bipolar disorder but has not been well studied (Brotman et al., 2006). This irritability is associated with substantial suffering in the children them- selves, reflecting as it does chronically high rates of negative affect and marked disruption of family life. Although these broader definitions of symptoms do display some similarities with more classic bipolar disorder symptoms (Biederman et al., 2000, 2005), the danger is that these children are being misdiag- nosed when they might better meet criteria for more classic diagnostic categories, such as attention-deficit/hyperactivity disorder (ADHD) or conduct disorder (see Chapter 15). In that case, the very potent drug treatments for bipolar disorder with substantial side effects would pose more risks for these children than they would benefits. But these cases also differ from more typical conduct or ADHD conditions as well, since it is the intense negative affect that seems to be driving the irritability and marked inability to regulate mood. In view of the distinctive features of this condition reviewed above, it seemed very impor- tant to better describe these children up to 12 years of age as suffering from a diagnosis termed disruptive mood dysregulation disorder rather than have them continue to be mistakenly diag- nosed with bipolar disorder or perhaps conduct disorder (Roy et al., 2014). Criteria for this new disorder are presented in DSM Table 8.5. In one case seen at our clinic, a nine-year-old girl we will call Betsy was brought in by her father for evaluation for severe anxiety. The father described a situation in which Betsy, a very bright child from an upper middle class family who had done well in school, was continually irritable and increasingly unable to get along at home, engaging in intense arguments, particularly with her mother, at the slightest provocation. Her mood would then deteriorate into a full-blown aggressive temper tantrum, and she would run to her room and on occasion begin throwing things. She began refusing to eat meals with the family, since bitter argu- ments would often arise, and it just became easier to allow her to eat in her room. Since nothing else seemed to work to calm her down, her father resorted to something he used to do when she was a baby—take her for a long ride in the family car. After a while Betsy would begin to relax, but during one long ride she turned to her father and said, “Daddy, please help me feel better because if I keep feeling like this I just want to die.”
Adults with a history of disruptive mood dysregulation disorder are at increased risk for developing mood and anxiety disorders, as well as many other adverse health outcomes (Copeland et al., 2014). Therefore, a very important objective for the immediate future will be developing and evaluating both psychological and drug treatments for this difficult condition. For example, it is very possible that new psychological treatments under development for severe emotional dysregulation in children may be useful with this condition (Ehrenreich et al., 2009).
BIPOLAr DISOrDerS
CliniCal DesCription
The key identifying feature of bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes in an unending roller coaster ride from the peaks of elation to the depths of despair. Beyond that, bipolar disorders are parallel in many ways to depressive disorders. For example, a manic episode might occur only once or repeatedly. Consider the case of Jane.
Jane had bipolar II disorder, in which major depressive episodes alternate with hypomanic episodes rather than full manic episodes (see DSM Table 8.6). As we noted earlier, hypo- manic episodes are less severe. Although she was noticeably “up,” Jane functioned pretty well while in this mood state. The criteria for bipolar I disorder are the same, except the individual experi- ences a full manic episode. As in the criteria set for major depres- sive disorder, for the manic episodes to be considered separate, they must have a symptom-free period of at least two months between them. Otherwise, one episode is seen as a continuation of the last.
The case of Billy illustrates a full manic episode. This indi- vidual was first encountered when he was admitted to a hospital. During manic or hypomanic phases, patients often deny they have a problem, which was characteristic of Billy. Even after spending inordinate amounts of money or making foolish busi- ness decisions, these individuals, particularly if they are in the midst of a full manic episode, are so wrapped up in their enthusiasm and expansive- ness that their behaviour seems perfectly reasonable to them. The high during a manic state is so pleasurable, people may stop taking their medication during periods of distress or discouragement in an attempt to bring on a manic state once again; this is a serious challenge to professionals.
A milder but more chronic version of bipolar disorder is called cyclothymic disorder (Akiskal, 2009; Parker et al., 2012). Cyclothymic disorder is a chronic alternation of mood elevation and depression that does not reach the severity of manic or major depressive episodes (see DSM Table 8.7).
- individuals tend to be in one mood state or the other for many years with relatively few periods of neutral (or euthymic) mood. This pattern must last for at least two years (one year for children and adolescents) to
meet criteria for the disorder. Individuals with cyclothymic disorder alternate between the kinds of mild depressive symp- toms Jack experienced during his dysthymic states and the sorts of hypomanic episodes Jane experienced. In neither case was the behaviour severe enough to require hospitalization or immediate intervention. Much of the time, such individuals are just considered moody. However, the chronically fluctuating mood states are, by definition, substantial enough to interfere with functioning. Furthermore, people with cyclothymia should be treated because of their increased risk of developing the more severe bipolar I or bipolar II disorder (Akiskal, 2009; Goodwin & Jamison, 2007; Otto & Applebaum, 2011; Parker et al., 2012).
Additional Defining Criteria for Bipolar Disorders
For depressive disorders, we discussed additional defining crite- ria that may or may not accompany a mood disorder and noted that it was important to identify these specifiers or symptoms to plan the most effective treatment. All these specifiers apply to bipolar disorders (see DSM Table 8.4). Specifically, the cata- tonic features specifier applies mostly to major depressive episodes although rarely may apply to a manic episode. The psychotic features specifier may apply to manic episodes, during which it is common to have delusions of grandeur. The anxious distress specifier is also present in bipolar disorders, as it is in depressive disorders. New to the DSM-5 is the “mixed features” specifier, which, as in depressive disorders, is meant to
describe the major depressive or manic episode that has some symptoms from the opposite polarity; for example, a depressive episode with some manic symptoms. The seasonal pattern specifier may also apply to bipolar disorders. In the usual presentation, individuals may become depressed during the winter and manic during the summer. Finally, manic episodes may occur surrounding, but mostly after, childbirth in the peri- partum period.
Just as for depression, it is important to determine whether a patient suffering from a manic episode has had episodes of major depression or mania in the past, as well as whether the individual has fully recovered between past episodes. Just as it is important to determine if persistent depressive disorder preceded a major depressive episode, it is also important to determine whether cyclothymia preceded the onset of bipolar disorder. This is because the presence of cyclothymia predicts a decreased chance for a full inter-episode recovery (Akiskal, 2009).
Rapid-Cycling Specifier
One specifier is unique to bipolar I and II disorders: rapid-cycling specifier. Some people move quickly in and out of depressive or manic episodes. An individual with bipolar disorder who experi- ences at least four manic or depressive episodes within a year is considered to have a rapid-cycling pattern, which appears to be a severe variety of bipolar disorder that does not respond well to standard treatments (Angst, 2009; Kupka et al., 2005; Schneck et al., 2004, 2008). Coryell and colleagues (2003) demonstrated a higher probability of suicide attempts and more severe episodes of depression in 89 patients with a rapid-cycling pattern compared with a non-rapid-cycling group. Kupka and colleagues (2005) and Nierenberg and colleagues (2010) also found these patients’ symptoms were more severe on a number of measures. Some evidence indicates that alternative drug treatment, such as anti- convulsants and mood stabilizers, rather than antidepressants, may be more effective with this group of patients (Kilzieh & Akiskal, 1999).
Approximately 20 to 50 percent of bipolar patients experience rapid cycling. From 60 to 90 percent are female, a higher rate than in other variations of bipolar disorder (e.g., Altshuler et al., 2010; Coryell et al., 2003; Kupka et al., 2005; Schneck et al., 2004), and this finding is consistent across 10 studies (Kilzieh & Akiskal, 1999). In most cases, rapid cycling tends to increase in frequency over time and can reach severe states in which patients cycle between mania and depression without any break. When this direct transition from one mood state to another happens, it is referred to as rapid switching or rapid mood switching and is a particularly treatment-resistant form of the disorder (MacKinnon et al., 2003; Maj et al., 2002). Interestingly, one precipitant of rapid cycling may be taking antidepressant medication, which is prescribed for some individuals with bipolar disorder, because the frequency of rapid cycling is considerably higher among those taking antidepres- sants compared with those who are not taking them (Schneck et al., 2008). Fortu- nately, rapid cycling does not seem to be permanent, because only 3 to 5 percent of patients continue with rapid cycling across a five-year period (Coryell et al., 1992; Schneck et al., 2008), with 80 percent returning to a non–rapid-cycling pattern within two years (Coryell et al., 2003). There are also cases of ultra-rapid cycle lengths that only last for days to weeks and ultra-ultra-rapid cycling in cases where cycle lengths are less than 24 hours
(Wilk & Hegerl, 2010). In ultra-ultra-rapid cycling, switches into depression occurred at night and switches into mania occurred at daytime, suggesting a link to circadian aspects.
onset anD Duration
The average age of onset for bipolar I disorder is 18, and for bipolar II disorder it is 22, although cases of both can begin in childhood (Angst, 2009; Judd et al., 2003; Merikangas & Pato, 2009). This is somewhat younger than the average age of onset for major depres- sive disorder, and bipolar disorders begin more acutely; that is, they develop more suddenly (Angst & Sellaro, 2000; Johnson, Turkheimer, et al., 2009). About one-third of the cases of bipolar disorder begin in adolescence (Taylor & Abrams, 1981), and the onset is often preceded by minor oscillations in mood or mild cyclo- thymic mood swings (Goodwin & Jamison, 2007; Merikangas et al., 2007). Only 10 to 13 percent of bipolar II disorder cases progress to full bipolar I syndrome (Coryell et al., 1995; Depression Guideline Panel, 1993). The distinction between unipolar and bipolar mood disorder also seems well defined because only 5 percent of a large group of 381 patients with unipolar depression experienced a manic episode during a 10-year follow-up period (Coryell et al., 1995), although Angst and Sellaro (2000), in reviewing some older studies, estimated the rate of individuals with depression later experiencing mania at closer to 25 percent. In any case, if these disorders were more closely related, we would expect to see more individuals moving from one to the other.
It is relatively rare for someone to develop bipolar disorder after the age of 40. Once it does appear, the course is chronic; that is, mania and depression alternate indefinitely. Therapy usually involves managing the disorder with ongoing drug regimens that prevent recurrence of episodes. Suicide is an all-too-common consequence of bipolar disorder, usually occurring during depres- sive episodes, as it did in the case of Jane (Angst, 2009; Valtonen et al., 2007). A large Swedish study showed that, on average, people with bipolar disorder died eight to nine years earlier of various medical diseases and suicide than did the general population (Crump et al., 2013). When patients receive treatment early, however, the mortality rate was comparable to that of the general population. Bipolar disorder is associated with a high risk of suicide attempts and suicide death, the latter being associated with male sex and having a first-degree relative who committed suicide (Schaffer et al., 2015). The risk of suicide is not limited to Western countries but occurs in countries around the world (Meri- kangas et al., 2011).
In typical cases, cyclothymia is chronic and lifelong. In about one-third to one-half of patients, cyclothymic mood swings develop into full-blown bipolar disorder (Kochman et al., 2005; Parker et al., 2012). In one sample of cyclothymic patients, 60 percent were female, and the age of onset was often during the teenage years or before, with some data suggesting the most common age of onset to be 12 to 14 years (Goodwin & Jamison, 2007). The disorder is often not recognized, and sufferers are thought to be high-strung, explosive, moody, or hyperactive (Akiskal, 2009; Goodwin & Jamison, 2007). One subtype of cyclothymia is based on the predominance of mild depressive symptoms, one on the predominance of hypomanic symptoms, and another on an equal distribution of both.
PreVALenCe Of MOOD DISOrDerS
In the 2017 Canadian Community Health Survey (CCHS), about 2.6 million Canadians, 8.6 percent of the population 12 years of age or older, reported that they have a mood disorder, such as depression, bipolar disorder, mania, or dysthymia (Statistics Canada, 2018). Half of this group reported that they also have been diagnosed with an anxiety disorder.
With regard to depression specifically, the best estimates of the worldwide prevalence suggest that approximately 16 percent of the population experience major depressive disorder over a life- time, and approximately 6 percent have experienced a major depressive disorder in the last year (Hasin et al., 2005; Kessler et al., 2003; Kessler, Chiu, et al., 2005). Two community studies conducted in large urban centres, one in Toronto by De Marco (2000) and a second in Calgary by Patten (2000), show similar one-year prevalence rates for major depression, 10.4 and 11 percent, respectively. However, estimates of the Canadian population based on two cycles of the CCHS (2002 and 2012) were lower, documenting annual prevalence for major depression to be 4.7 and 4.8 percent and estimating the lifetime prevalence at 12.2 and 11.3 percent (Patten et al., 2016; Pearson et al., 2013).
As Roger Bland, a leading psychiatric epidemiologist from the University of Alberta, has pointed out, different research methods may account for the differing rates of prevalence (Bland, 1997). Scott Patten at the University of Calgary concurred (Patten, 2000) but also provided another explanation for different prevalence rates: prevalence rates for depression in Canada appear to be decreasing, suggesting progress in public health efforts toward combating depression in our country (Patten, 2002). Patten’s more recent work with the 2002 and 2012 CCHS found support for an increase in the proportion of Canadians receiving treatment for major depression—however, the evidence did not support a reduction in the annual prevalence rate of major depression as it remained essentially the same, about 5 percent, over the 10-year period (Patten, 2016).
Women are about twice as likely to have mood disorders as men. For example, in the 2012 CCHS, the annual prevalence of major depressive episode for women was 5.8 percent and for men was 3.6 percent (Pearson et al., 2012; see ■ Figure 8.2). In fact, women were more likely to have a major depressive episode than men in all age groups except those 65 years and older. Bipolar disorders are distributed approximately equally across gender (Merikangas & Pato, 2009).
LIfeSPAn DeVeLOPMenTAL InfLuenCeS On MOOD DISOrDerS
The prevalence of mood disorders varies with age, and age and development also affect many of the characteristics of mood disorders. We review and highlight these developmental characteristics—first for children and adolescents, and then for older adults.
Mood disorders - in ChilDren anD aDolesCents
You might assume that depression requires some experience with life, that an accumulation of negative events or disappointments might create pessimism, which then leads to depression. Like many reasonable assumptions in psychopathology, this one is not uniformly correct. There is some evidence that three-month-old babies can show signs of depression. Infants of depressed mothers display marked depressive behaviours (sad faces, slow movement, lack of responsiveness), even when interacting with a nonde- pressed adult (Garber et al., 2009; Guedeney, 2007). Whether this behaviour or temperament is caused by a genetic tendency inher- ited from the mother, the result of early interaction patterns with a depressed mother or primary caregiver, or a combination is not yet clear.
Most investigators agree that mood disorders are fundamentally similar in children and in adults (Brent & Birmaher, 2009; Garber et al., 2009; Weiss & Garber, 2003). Therefore, no “childhood” mood disorders in the DSM-5 are specific to a developmental stage, with the exception of disruptive mood dysregulation disor- der, which can be diagnosed only up to 12 years of age. This is unlike the anxiety disorders in which a number of conditions occur only early in development. It seems clear, however, that the look of depression changes with age. For example, children under three years of age might manifest depression by their facial expressions, as well as by their eating and sleeping. In the extreme, this could develop into disruptive mood dysregulation disorder. In children between the ages of 9 and 12, many of these features would not occur. Psychologist Ian Gotlib, formerly of the University of West- ern Ontario, has shown that adolescents who are forced to limit their activities because of illness or injury are at high risk for depression (Lewinsohn et al., 1997).
Estimates on the prevalence of mood disorders in children and adolescents vary widely, although more sophisticated studies are beginning to appear. The general conclusion is that depressive disorders occur less frequently in children than in adults but rise dramatically in adolescence, when, if anything, depression is more frequent than in adults (Kashani et al., 1987; Kessler et al., 2012; Petersen et al., 1993; Rohde et al., 2013). In their study of major depressive disorder, Patten and his colleagues found evidence of a decline in annual prevalence rates from adolescence to adulthood. The 2002 and the 2012 cycles of the CCHS targeted Canadians 15 years of age or older and Patten and his colleagues (2006, 2015) found the highest annual prevalence rates occurred in the youngest age group and that there was a tendency for the rates to decline with age. The 2012 CCHS data have also been used to document this decline for annual rates of major depressive episode (Pearson et al., 2013; see ■ Figure 8.2).
Furthermore, some evidence indicates that, in young children, dysthymia is more prevalent than major depressive disorder, but this ratio reverses in adolescence. Like adults, adolescents experi- ence major depressive disorder more frequently than dysthymia (Kashani et al., 1983; Kashani et al., 1987). Major depressive disorder in adolescents is also largely a female disorder (Santor & Kusumakar, 2001), as it is in adults, although this is not true for more mild depression. Only among the adolescents referred to treatment does the gender imbalance exist (Compas et al., 1997), though why more girls reach a more severe state requiring referral to treatment is not clear.
As far as mania is concerned, children under the age of nine seem to present with more irritability and emotional swings as compared with classic manic states, and they are often mistaken as being hyperactive. In addition, their symptoms are more chronic in that they are always present rather than episodic as in adults (Biederman et al., 2000). This presentation seems to continue through adolescence (Faraone et al., 1997), although adolescents may appear more typically manic. Bipolar disorder seems to be rare in childhood, although case studies of children as young as four years of age displaying bipolar symptoms have been reported (Poznanski et al., 1984), and the diagnosis may be mistaken for conduct disorder or ADHD. However, the preva- lence of bipolar disorder rises substantially in adolescence, which is not surprising in that many adults with bipolar disorder report a first onset during the teen years (Keller & Wunder, 1990). “Emotional swing,” or oscillating manic states that are less distinct than in adults, may also be characteristic of children, as are brief or rapid-cycling manic episodes lasting only part of a day (Youngstrom, 2009).
One developmental difference between children and adoles- cents compared with adults concerns patterns of comorbidity. For example, childhood depression (and mania) is often associated with and sometimes misdiagnosed as ADHD or, more often, conduct disorder in which aggression and even destructive behav- iour are common (Fields & Fristad, 2009; Garber et al., 2009). Conduct disorder and depression often co-occur in bipolar disor- der. But, once again, many of these children might now meet the criteria for disruptive mood dysregulation disorder, which would better account for this comorbidity. In any case, successful treat- ment of the underlying depression (or spontaneous recovery) may resolve the associated ADHD or conduct disorder in these patients. Adolescents with bipolar disorder may also become aggressive, impulsive, sexually provocative, and accident prone (Carlson, 1990; Keller & Wunder, 1990).
Whatever the presentation, mood disorders in children and adolescents are very serious because of their likely consequences. In an important prospective study, conducted as part of the Ontario Child Health Study, Fleming, Boyle, and Offord (1993) followed 652 adolescents with either a major depressive disorder or a conduct disorder for four years. These adolescents largely continued to experience serious problems and markedly impaired functioning. Lewinsohn, Rhode, Seeley, Klein, and Gotlib (2000) also followed 274 adolescents with major depressive disorder into adulthood and identified several risk factors for additional depres- sive episodes as adults. Prominent among these were conflicts with parents, being female, and a higher proportion of family members experiencing depressive episodes. Their more recent longitudinal work shows that young adults who had experienced an episode of major depressive disorder in adolescence exhibited a very pervasive pattern of psychosocial impairments in areas such as interpersonal functioning, quality of life, and occupa- tional performance. Reduced life satisfaction in young adulthood was uniquely associated with a history of major depressive disor- der, rather than with a history of other mental disorders, in adoles- cence. These findings underline the seriousness of adolescent depression, in terms of negative consequences continuing into adulthood.
Mood disorders - older adults
Only recently have we seriously considered the problem of depression in older adults (Wittchen, 2012). A Canadian study by Dalhousie University researcher Kenneth Rockwood and colleagues estimated that 18 to 20 percent of nursing home residents may experience major depressive episodes (Rockwood et al., 1991; see also Katz et al., 1989), which are likely to be chronic if they appear first after the age of 60 (Rapp et al., 1991). Late-onset depressions are associated with marked sleep difficul- ties, illness anxiety disorders, and agitation. It can be difficult to diagnose depression in seniors because the presentation of mood disorders is often complicated by the presence of medical illnesses or symptoms of dementia (e.g., Blazer, 1989; Small, 1991). That is, seniors who become physically ill or begin to show signs of dementia might become depressed about it, but the signs of depression would be attributed to the illness or dementia and thus missed. Nevertheless, the overall prevalence of major depressive disorder is the same or slightly lower in the older adults as in the general population (Patten et al., 2006; Weissman et al., 1991), perhaps because stressful life events that trigger major depressive episodes decrease with age. But, as noted by Ian Gotlib, milder symptoms that do not meet the criteria for major depressive disorder may be more common among seniors (Gotlib & Nolan, 2000), perhaps because of illness and infirmity (Roberts et al., 1997).
Anxiety disorders frequently accompany depression in seniors (in about a third of cases), particularly generalized anxiety disor- der and panic disorder (Lenze et al., 2000), and when they do, patients are more severely depressed. In the DSM-5, as described earlier, clinicians now must specify the presence and severity of anxiety when diagnosing a mood disorder because of the implica- tions for severity and course of the mood disorder, as well as for treatment. Depression can also contribute to physical disease in seniors (Whooley & Wong, 2013). In fact, being depressed doubles the risk of death in older adults who have suffered a heart attack or stroke (Schulz et al., 2002).
The earlier gender imbalance in depression disappears after the age of 65. In early childhood, boys are more likely to be depressed than girls, but an overwhelming surge of depression in adolescent girls produces an imbalance in the sex ratio (Santor & Kusumakar, 2001) that is maintained until old age, when just as many women are depressed, but increasing numbers of men are also affected (Wallace & O’Hara, 1992). From the perspective of the lifespan, this is the first time since early childhood that the sex ratio for depression is balanced.
Mood disorders - across cultures
We noted the strong tendency of anxiety to take very physical or somatic forms in some cultures; instead of talking about fear, panic, or general anxiety, many people describe stomachaches, chest pains or heart distress, and headaches. Much the same tendency exists across cultures for mood disorders (Kim & Lopez, 2014), which is not surprising, given the close relation- ship of anxiety and depression (Kessler & Bromet, 2013). Feelings of weakness or tiredness particularly characterize depression that is accompanied by mental or physical slowing or retardation.
Although somatic symptoms that characterize mood disorders seem roughly equivalent across cultures, it is difficult to compare subjective feelings. The way people think of depression may be influenced by the cultural view of the individual and the role of the individual in society (Kleinman, 2004; Ryder et al., 2008). For example, in societies that focus on the individual instead of the group, it is common to hear statements such as “I feel blue,” or “I am depressed.” In cultures where the individual is tightly integrated into the larger group, however, someone might say, “Our life has lost its meaning,” referring to the group in which the individual resides (Manson & Good, 1993). Despite these influ- ences, it is generally agreed that to study the nature and preva- lence of mood disorders (or any other psychological disorder) in other cultures is first to determine their prevalence by using stan- dardized criteria (Neighbors et al., 1989). The DSM criteria are increasingly used, along with semistructured interviews in which the same questions are asked, with some allowances for different words that might be specific to a culture or subculture.
One such study is the International Consortium of Psychiatric Epidemiology study, which used the same structured interview and diagnostic criteria in ten countries, including Canada (Andrade et al., 2003). The Canadian data were collected by a team led by David Offord of the Chedoke-McMaster Hospital in Hamilton, Ontario. As shown in ■ Figure 8.3, the highest rates of major depressive episode were observed in the U.S. sample (17 percent prevalence), and the lowest in the Japanese sample (3 percent prevalence). Compared with the prevalence rates in the other countries, the rates in the Canadian sample were moder- ate (8 percent prevalence).
As noted by Laurence Kirmayer (Kirmayer et al., 2000; Kirmayer, Simpson, & Cargo, 2003), the appalling social and economic conditions faced by many groups of Indigenous Peoples in North America, as well as their long history of cultural oppression and marginalization, fulfill all the require- ments for chronic major life stress, which is strongly related to the onset of mood disorders, particularly major depressive disorder. Kinzie, Leung, Boehnlein, and Matsunaga (1992) used a structured interview to determine the percentage of adult members of a First Nations reserve who met the criteria for mood disorders. The lifetime prevalence for any mood disorder was 19 percent in men, 37 percent in women, and 28 percent overall, approximately four times as high as in the general popu- lation. Examined by disorder, almost all the increase is accounted for by greatly elevated rates of major depression. A study of mental health services use among the Cree of James Bay, Québec, indicated that depression was the most common psychi- atric illness, occurring in 16 percent of the 242 Cree people who were receiving treatment by nursing or other medical profes- sionals in the region (Lavallee et al., 1991). Similar findings emerged in a study conducted in a Canadian Arctic Inuit community of about 1100 people (Haggarty et al., 2000): This study revealed an estimated rate of past-week depression of 26 percent—a rate that is much higher than that seen in the general population.
More recently, and using data from the CCHS, Statistics Canada (2016a) documented the four-year prevalence rates (2011–2014) of mood disorders (i.e., depression, bipolar disorder, mania, or dysthymia) by Aboriginal identity among Canadians 12 years of age or older. The estimates were higher among the First Nations population living off-reserve (12 percent) and Métis (12.6 percent) than among the non-Aboriginal identity population (7.2 percent). In all groups, the rates for women were higher than for men. It is important to remember that the CCHS excludes persons living on reserves and other settlements in the provinces. The First Nations Regional Health Survey provided estimates for mood disorders among First Nations living on reserve (First Nations Information Governance Centre, 2018a, 2018b). Estimates based on data collected during 2015–2016 were that 7.8 percent of adults and 6.6 percent of First Nations youth had been diagnosed with a mood disorder during this period, lower rates than those found in the First Nations off-reserve population from the CCHS.
Mood disorders - amonG the Creative
Is there truth in the enduring belief that “genius is allied with madness”? Several researchers have attempted to find out. The results are surprising. Handel wrote The Messiah in only three weeks, apparently during a manic episode, and Rossini composed The Barber of Seville in only 13 days during a likely period of hypomania (Endler, 1990). Table 8.1 lists a group of famous poets, many of whom won the coveted Pulitzer Prize. All almost certainly had bipolar disorder. Many committed suicide. These eight poets are among the 36 born in the 20th century who are represented in The New Oxford Book of American Verse, a collec- tion reserved for the most distinguished poets. It is certainly striking that about 20 percent of these 36 poets exhibited bipolar disorders, given the population prevalence of slightly less than 1 percent.
Many composers, artists, and writers, whether suspected of mood disorders or not, speak of periods of inspiration when thought processes quicken, moods lift, and new associations are generated. Perhaps something inherent in manic states fosters creativity, and recent studies confirm that creativity is specifically associated with manic episodes and not depressive states
(Soeiro-de-Souza et al., 2011). But, as noted by the late Norman Endler (1990), “It is one thing to have the high degree of energy that exists in a manic state; it is another thing to channel it in a direction that creates new works and accomplishes effective tasks” (p. 19). It is also possible that the genetic vulnerability to mood disorders is independently accompanied by a predisposi- tion to creativity. In other words, the genetic patterns associated with bipolar disorder may also carry the spark of creativity. Yet another possibility is suggested by the work of Ghadirian, Gregoire, and Kosmidis (2001), Montréal researchers who conducted a scientific study into the relationship of bipolar disor- der to creativity. They compared a group of 20 patients with bipolar disorder to a group of 24 patients with other mental health disorders on measures of creativity. While the bipolar patients were not any more creative than the patients with other disorders, the researchers did find that moderately ill patients were signifi- cantly more creative than severely ill patients. These findings suggest that creativity may peak at a stage of the illness where symptoms are moderate but that creativity may actually decline as symptoms become progressively worse. These various possibili- ties are little more than speculations at present, but the study of creativity and leadership, so highly valued in all cultures, may well be enhanced by a deeper understanding of psychological disorders.
CAuSeS Of MOOD DISOrDerS
In Chapter 2, we described equifinality as the same end product resulting from possibly different causes. Just as a fever may have many causes, depression may also have a number of causes. For example, a depressive disorder that arises in winter has a different precipitant than a severe depression following a death, even though the episodes might look quite similar. Nevertheless, psychopathologists are identifying biological, psychological, and social factors that seem strongly implicated in the etiology of mood disorders, whatever the precipitating factor. An integrative theory of the etiology of mood disorders considers the interaction of biological, psychological, and social dimensions and also notes the very strong relationship between anxiety and depression.
Familial and Genetic Influences
In family studies, we look at the prevalence of a given disorder in the first-degree relatives of an individual known to have the disor- der (the proband). We have found that, despite wide variability, the rate in relatives of probands with mood disorders is consistently about two to three times that in relatives of people who don’t have mood disorders (Klein et al., 2002; Lau & Eley, 2010; Levinson, 2009). Increasing severity, recurrence of major depression, and earlier age of onset in the proband is associated with the highest rates of depression in relatives (Kendler et al., 2007; Klein et al., 2002; Weissman et al., 2005).
The best evidence that genes have something to do with mood disorders comes from twin studies, in which we examine the frequency with which identical twins (with identical genes) have the disorder, compared with fraternal twins, who share only 50 percent of their genes (as do all first-degree relatives). If a genetic contribution exists, the disorder should be present in identical twins to a much greater extent than in fraternal twins. Several twin studies, including those by Randy Katz and colleagues, suggest that the mood disorders are heritable (e.g., Hodgson & McGuffin, 2013; McGuffin et al., 2003). In a large meta-analysis of twin studies, Sullivan et al. (2000) estimated the heritability of depression to be 37 percent. Shared environmental factors have little influence, whereas 63 percent of the variance in depression can be attributed to nonshared environmental factors.
Two reports have appeared suggesting sex differences in genetic vulnerability to depression. Bierut et al. (1999) studied 2662 twin pairs in the Australian twin registry and found the characteristically higher rate of depressive disorders in women. Estimates of heritability in women ranged from 36 to 44 percent, consistent with other studies. But estimates for men were lower and ranged from 18 to 24 percent. These results agree for the most part with an important study of men in North America by Lyons et al. (1998). The authors conclude that environmental events play a larger role in causing depression in men than in women.
Note that bipolar disorder confers an increased risk of devel- oping some mood disorder but not necessarily bipolar disorder. This conclusion supports the notion that bipolar disorder may simply be a more severe variant of mood disorders rather than a fundamentally different disorder. Then again, of identical twins concordant for a mood disorder, 80 percent are also concordant for polarity. This finding suggests that these disorders may be inherited separately and may therefore be separate disorders after all (Nurnberger, 2012; Nurnberger & Gershon, 1992). A twin study drew similar conclusions and noted that most of the genetic variance in vulnerability to bipolar disorder is specific to the bipo- lar syndrome (McGuffin et al., 2003).
McGuffin and colleagues (2003) concluded that both points are partially correct. They found that the genetic contributions to depression in both disorders are the same or similar but that the genetics of mania are distinct from depression. Thus, individuals with bipolar disorder are genetically susceptible to depression and independently genetically susceptible to mania. This hypoth- esis still requires further confirmation.
Although research continues to raise questions about the rela- tive contributions of psychosocial and genetic factors to mood disorders, overwhelming evidence suggests that such disorders are familial and almost certainly reflect at least a small underlying genetic vulnerability, particularly for women. As with other psychological disorders, it seems unlikely that we will find any single dominant gene that is responsible, although occasional reports appear to that effect.
In conclusion, the best estimates of genetic contributions to depression fall in the range of approximately 40 percent for women, but seem to be significantly less for men. Genetic contribu- tions to bipolar disorder seem to be somewhat higher. Behavioural geneticists break down environmental factors into events shared by twins (experiencing the same upbringing in the same house, and perhaps, experiencing the same stressful events) and events that are not shared. What part of our experience causes depression? Wide agreement exists that it is the unique nonshared events, rather than what is shared, that interact with biological vulnerability to cause depression (Bierut et al., 1999; Plomin et al., 1997).
