“I
have of late--but wherefore I know not--lost all my mirth, forgone all custom
of exercises, and indeed it goes so heavily with my disposition that this
goodly frame, the earth, seems to me a sterile promontory.” Hamlet, Act II, Sc.
2.
LECTURE 6
MOOD DISORDERS
Dale L. Johnson
Rachmaninoff was depressed and
unable to compose music. He went to a psychologist who told him to repeat over
and over all day, "I will write a great symphony." His depression
lifted, but he did not write a great symphony; he wrote his great Piano
Concerto Number 2.
The list of famous people who have
had an affective disorder is long. It includes Ernest Hemingway, Kate Millett,
Rod Steiger, Patty Duke, Abraham Lincoln, Winston Churchill, Calvin Coolidge,
Sergei Rachmaninoff, Gustav Mahler, Clinton’s health advisor, Robert Boorstein,
Clinton's counsel, Vince Foster, William James, O. Hobart Mowrer, Kay Jamison,
William Styron, Vincent Van Gogh, Silvia Plath, and all of the writers of
Saturday Night Live (or so I was told).
Affective disorders have come to be
recognized as a major disability by public health researchers. The World Health
Organization report by C. Murray and A. Lopez, The global burden of disease,
1996, ranks major causes of disability world-wide. Using as their measure, the
Disability Adjusted Life Year (DALY) they found major depressive disorder was
number one, followed by iron-deficiency anemia, falls, alcohol use, heart
disease, bipolar disorder, congenital anomalies, osteoarthritis, schizophrenia
and obsessive-compulsive disorder. Thus, affective disorders disable hundreds
of thousands of people everywhere in the world. Major depressive disorder is
the most disabling condition in both developed and developing nations.
More
Information About Mood Disorders
URLs
Bipolar
Disorder
www.ndmda,org. A consumer's
organization.
www.aafp.org/afp/20000915/1343.html
www.guidelines.com/bp2000gl.pdf An introduction to treatment.
www.psychiatrist.com/bauer/cpgindex_b.htm
www.bpkids.org/printing/004.htm Information about children.
Mood
Disorders
www.vh.org/Providers/ClinRef/FPHandbook/Chapter15/01-15.html
Depression
www.ama.assn.org/insight/spec_con/depressn/depressn.htm
www.depression.com
www.depression.fallout.com
depression.mentalhelp.net
www.depression-info.com/cgi-bin/welcome.pl
www.healingwell.com/depression
Self-Help
Books
Burns,
D. D. (1980). Feeling good: The new mood therapy. New York: Signet. This
is excellent. Anyone who is depressed or thinks she or he may be depressed should
read it and follow the suggestions.
General Characteristics of Depression and Mania
Although the DSM-IV has some mention
of 11 types of affective disorder we will be concerned here with only a few.
The two most common ones are major depressive disorder and bipolar disorder.
____________________________________________________________
DSM-IV Criteria for MAJOR DEPRESSIVE DISORDER
A. One or more distinct periods with dysphoric
mood or pervasive loss of interest or pleasure.
B. Four or more of the following:
1.
Increase or decrease in appetite or weight.
2.
Excessive or insufficient sleep
3.
Low energy, fatiguability tiredness
4. Psychomotor agitation or retardation
5.
Loss of interest or pleasure in usual activities
6.
Feelings of self-reproach, guilt
7.
Decreased ability to think or concentrate
8.
Recurrent thoughts of death or suicide
C. Duration of dysphoric features for at least
2 weeks.
D. No other major diagnosis (e.g.,
schizophrenia, organic mental disorder)
____________________________________________________________
DSM-IV
Criteria for Manic Episode
A.
A distinct period of abnormally and persistently elevated, expansive, or
irritable mood.
B.
During the period of mood disturbance, at least three of the following symptoms
have persisted (four if the mood is only irritable) and have been present to a
significant degree:
(1) Inflated self-esteem or
grandiosity.
(2) Decreased need for sleep.
(3) More talkative than usual or
pressure to keep talking.
(4) Flight of ideas.
(5) Distractibility, attention
easily drawn to unimportant or irrelevant external stimuli.
(6) Increase in goal-directed
activity (either socially, at work or school, or sexually) or psychomotor
agitation.
(7) Excessive involvement in
pleasurable activities which have a high potential for painful consequences.
C.
Mood disturbance sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others.
D.
At no time during the disturbance have there been delusions or hallucinations
for as long as two weeks in the absence of prominent mood symptoms.
____________________________________________________________
Either of the two forms of disorder
described above may occur alone. It is common for major depressive disorder to
occur by itself, but mania is usually accompanied by depression. In addition
there are several other variations on the two major themes.
Dysthymia is a milder form of
depression, but it is long-lasting and has insidious effects on the persons
occupational and social relations.
There are several formal diagnostic
listings:
Major depression, single episode
Major depression, recurrent
2 or more episodes, at
least 2 months apart. If one recurrence, odds of a third are very high, 80%.
Double depression. Depressive
episodes and dysthymia occurring together.
---------------------------------------------------------------------------------------------------------
Statistics and Course of
Depressive Disorders
Onset: 27 years.
[see prevalence table below based on
Kessler, Archives of General Psychiatry, 1994]
Is depression increasing worldwide?
The best answer is that no one knows because data are lacking over long time
periods. As you can see in textbook Figure 7.3. People born more recently
report more life-time depression, but this could be a memory effect. Older
people may have had depressive episodes but forget about some of the episodes
or tend to minimize their significance in retrospect.
The course of affective disorders is
episodic. People usually recover spontaneously from depressive episodes,
but dysthymia is persistent.
Bipolar
Disorder
There is a milder form than that
shown in the criteria above called cyclothymic disorder. It is less severe and
more chronic, but otherwise has some of the same features.
In a sub-type, bipolar II, major
depressive episodes alternate with hypomanic episodes rather than full manic
episodes. In bipolar I, the person has full manic episodes.
Kindling is a term that is used to
describe some bipolar episodes. In this there is rapid cycling. It is a
particularly severe form and does not respond well to drug treatment.
Antidepressant medications may provoke a cycle. This happens to about 20% of
bipolar patients.
____________________________________________________________
Prevalence of Mood Disorders
Lifetime 12 Months
Male Female Male Female
Major
Depression 12.7 21.3 7.7 12.9
Manic 1.6 1.7
1.4 1.3
Dysthymia 4.8 8.0 2.1 3.0
Any 14.7 23.9 8.5 14.1
____________________________________________________________
Onset: The average age is 18 years
for bipolar I, and 22 for bipolar II.
The course is chronic.
Note that more females are depressed
than males. This is a consistent finding at all ages after puberty. Why should
this be so? Any answer must be complex, but a few things are known:
1) Girls worry more about their
bodies during adolescence and are more likely to be dissatisfied with them
(Merten, B., & Lewinsohn, P. Journal of Abnormal Psychology, 1990).
2) Premenstral tension is associated
with depressed mood. Depending on when the prevalence survey is done some women
will be at a pre-menstral tension phase and will report feeling tense and often
depressed.
3) Girls and women have stronger
social network ties and a stronger interest in maintaining these ties. If
social networks are not functioning the person is likely to be depressed.
4) An expressive style used more
commonly by women may lead to greater reporting of what are taken as depressive
symptoms.
5) A greater sense of
"helplessness" in the face of troubles.
6) A tendency to amplify depressive
moods. Women are more likely to ruminate about sad feelings and to allow them
to feed on themselves. Depression begets depression (Nolen-Hoeksema, Psychological
Bulletin, 1987, vol. 101).
7) The findings may be an artifact
of American culture. In Amish society, where men do not drink or use drugs,
rates of depression are the same for men and women.
Also, do not forget: boys and men do
get depressed. It is not only a problem for girls and women.
Additional Defining Criteria
for Mood Disorders
Specifiers
These are additional characteristics
of some cases of mood disorder. They include psychotic symptoms such as
hallucinations and/or delusions. Psychotic depressive episodes are typically
treated with antidepressant and anti-psychotic medications.
Melancholic features such as early
morning waking, loss of libido, loss of appetite, loss of pleasure may be
present. These may respond better to electroconvulsive therapy (ECT).
One so-called atypical form is the
presence of anxiety. Actually, this is not so atypical. Depression and anxiety
are often found together.
Postpartum onset of depression. The four week period following childbirth is
a time for greater risk for depression. Undoubtedly important in this is
physical exhaustion. Post-partum blues are fairly common in the United States,
but are unheard of in some other cultures.
When I asked Navajo women if they knew of any women who became depressed
after having a baby they were incredulous. They said, "Why would a woman
be depressed after having a baby?"
Seasonal Affective Disorder
(SADs)
In the most common form of this
disorder, depression begins in late fall and continues to spring. It affects about
5% of population. In winter depression
there is a tendency to sleep more and to have increased appetite and weight
gain, as in atypical depression.
This form of depression may be
related to the production and circulation of melatonin which is secreted by the
pineal gland. There is a higher prevalence in the northern latitudes. However,
here is the puzzler: a recent study found no evidence of seasonal affective
disorder in Iceland where the sun does not appear for a long time in the
winter. Why don't Icelanders have SADs? Are Icelanders immune for genetic
reasons?
Treatment includes exposure to very
bright light immediately upon awakening in the morning. Morning light seems
especially efficacious. With this the patient should see an improved mood in
3-4 days. It is important the person not expose self to bright lights in the
evening.
Grief
When a loved one dies there is a high likelihood of
depression (62%), but in most cases this is transitory.
The best treatment seems to be to confront the death and
work it through. That is, to explore
the meaning of the loss and to express the full range of emotions including
anger. Exploring usually means talking about the death with intimate
confidants, good friends.
Funeral rituals are designed to help survivors cope with
grief. These are formalized activities involving a social group. There is
support and understanding, and the ritual marks an end point. This is it. The
loved one is dead. We all die. Now the living get on with their lives.
Additional Statistics and Course for Mood Disorders
11% of adults with depression are unemployed.
44% absenteeism, decreased productivity
Many lose jobs because of depression-related performance
in adequacies. Chief among these are loss of interest and motivation and, quite
often, development of a critical or negativistic interpersonal style. It has
been said that it is difficult to live with a depressed person.
Mood Disorders in Children and Adolescents.
It is a relatively recent discovery that children can be
depressed, although teachers and parents knew it long ago. The problem was in
the dominance of psychoanalytic theory which held that depression required a
superego, and children did not have a fully formed superego.
To age three depression is revealed in facial or body
expression, eating, sleeping and play. In older children depression is known
because the person says something about it. In this the older child is more
like an adults
There is a rise in incidence of depression with age and
it becomes especially high in adolescence.
Depression and Aggression.
Some children tend to become aggressive when depressed.
It is a statement by the child that “The world is no good.” Much of this is the
angry behavior that is is commonly diagnosed as conduct disorder. When I was a
consultant for Head Start at Allen Parkway Village (now gone) in Houston, I was
asked to come immediately to examine a 4-year-old boy. He was extremely
aggressive. He threw heavy objects at other children and teachers. He kicked
smaller children as they sat on the floor playing. I observed his behavior and
found he did not hit children larger than himself, but otherwise was
indiscriminate in his aggression. I asked one large teacher to station herself
near him and if he seemed ready to throw something, she was to enfold him with
her arms and hold him for 30 seconds. This put a stop to the aggressive
behavior, but now he spent the day under a table. I made a home visit and
discovered that the boy's father had left home after a big argument with the
boy's mother. Then, when the mother was at work, having left the children in
the care of an 8-year-old, a fire broke out in the apartment and the family's
infant burned to death. I had the head teacher engage the boy in play with fire
engines and he revealed that he felt he should have saved the baby. His mood
began to improve. Then, his father came home and all was well. His symptoms
disappeared.
Depression in Mothers and Effects on Children
The textbook does not discuss the very important topic of
the effects of depression in parents on their children. There is a vast
literature on this topic, but it is not on parents, it is on mothers. Somehow,
depression in fathers has been neglected, but it is not likely that their
having depression would not have an effect on their children. It may make
sense, however, to focus on mothers as they still, despite their numbers in the
workforce, have greatest responsibility for child care and all studies show,
spend more time with children.
When mothers have persistent depression their babies
sleep less well and are fussier. Their preschoolers have more sleep problems,
more conduct disorders, and more depression. Problems continue through the
childhood and adolescent years (see, for example, Gelfand, D. M. & Teti, D.
M. (1990). The effects of maternal depression on children. Clinical
psychology review, 10, 329-353.
The reasons for the problems are many. Certainly, one is
that the child may have inherited a disposition for depression and related
disorders such as anxiety. There are environmental possibilities as well.
People with depression show more aggravation with and negativity toward others,
and they are more critical. In two studies in Houston with our Parent-Child
Development Center, with Mexican American families, we found the single best
predictor of child behavior problems was the mother's frequent use of criticism
of her child. It occurred rarely, but when it did, it was related to behavior
problems.
There are other things, but they can be inferred from
understanding other characteristics of affective disorders.
Although the textbook does not discuss this problem
directly, it does discuss other characteristics of depression including effects
on social interaction that are relevant.
Elderly
20% of residents of nursing homes have depressive
episodes by some estimates. While the text emphasizes that the prevalence of
mood disorders is high among the elderly, we should also note that most elderly
people are doing well; they are not depressed and are not ill.
Mood Disorders Across Cultures
Each culture defines depression in its own way. For
example, my wife and I found that the Lakota Sioux of North and South Dakota
spoke of "tawatl yi sni," or
"totally discouraged" and emphasized that people who had this disorder
were obsessed with wanting to leave the earth and to go to the spirit world
with their ancestors.
Some cultures such as the Mexican culture may place
relatively more emphasis on physical aspects of depression. Even though there
are cultural differences in definition it is possible to use the same survey
instruments, when language translation is adequate, to gather information on
affective disorders everywhere. Furthermore, it appears that the response to
cognitive behavioral and interpersonal therapies is similar world-wide.
Anxiety and Depression
Almost everyone who is depressed is also anxious. One
likely reason for this is that there is genetic co-occurrence. Another
possibility is that our psychiatric classification system is just wrong. There
may not be two disorders, just one.
Causes of Mood Disorders
Genetic Data
Family
Studies
These have long shown
that heredity has something to do with depressive predisposition. The genetic contribution to the
development of bipolar disorder is especially high.
Twin
Studies
[See textbook Figure
7.3]
The evidence is strong for a genetic
involvement, especially for bipolar disorder.
Adoption
Studies
Mixed results.
Linkage
Studies
There are no confirmed reports of
which genes are involved in major depression. There are almost certainly
several genes involved in the development of bipolar disorder, but results to
date are inconsistent and difficult to interpret.
Biochemistry and Affective Disorders
Neurotransmitter
Systems
Although it is clear that the
neurotransmitter system is involved in the development of affective disorders
and how they change over time, the specific mechanisms for this are unclear.
Catecholamine
Hypothesis
Is depression associated with low levels of
norepinephrine (this is a catecholamine)? The idea came from the observation
that people who took reserpine for schizophrenia sometimes became very
depressed. The drug reduced norepinephrine levels.
Idolamine
Hypothesis
Low levels of serotonin are associated with or cause depression.
Successful treatment of depression reduces norepinephrine.
Permissive
Hypothesis
This assumes that low levels of serotonin cause of
depression, but sees this as a matter of interacting with other
neurotransmitter systems, including norepinephrine and dopamine.
Endrocrine System
Diseases affecting this system such as hypothyroidism
sometimes become depressed.
Sleep and Circadian Rhythms are altered with changes in
the endocrine system and sleep is disturbed in mood disorders. Depressed people
begin REM sleep quicker after falling asleep.
Insomnia triggers manic episodes.
All of this suggests that sleep and depression are
linked, perhaps with common pathways.
Psychological Dimensions
Context
and Meaning of Stressful Life Events
Rates of depression are higher for
people who experience a great deal of stress.
Psychoanalytic
Theory
The crux of this theory is that
depression occurs because anger is turned inward. When I worked as a
psychiatric aide at Menninger's in Topeka years ago, a very psychoanalytic
institution, we were directed to work with some patients in such a way that
they would get mad at us. Thus, the anger would be directed outward and the
depression would lift. I never saw it happen.
Behavioral
Theories
The listing that follows is only to
show that a great many clever people have tried to understand depression. And,
to some extent, all have contributed to the understanding we have today.
Ferster
1. Reduced positive reinforcement for adaptive
behavior results from loss of major reinforcers.
2. Social skills deficits impair ability to
recover from reduced positive reinforcement.
Lazarus
1. Loss of reinforcer
which was a discriminative stimulus leads to disruption of chain of behavior.
2. Receive positive
reinforcement for depressed behavior from others.
3. Undertake tasks they
fail to complete.
Lewinsohn
1. Low rate of
non-contingent positive reinforcement.
2. Social skills deficit
(less frequent and more non-contingent reinforcement of others)
3. Participate in fewer
rewarding activities.
4. More sensitive to
negative interpersonal interactions.
Cognitive Theories
Beck
Beck's
theory is especially important because it is the basis of cognitive-behavioral
therapy. This therapy has yielded better results for a wide variety of
disorders than any other therapy.
A.
Cognitions
1)
Consist of thoughts and images.
2)
Reflect unrealistically negative view of
Self
World
Future
3)
Based on schemas and are reinforced by current interpretation of events.
4)
Expains symptoms of a depressive sysndrome.
5)
Co-varies with the severity of symptoms
6) Logical errors
occur in conditions that are negatively distorted (arbitrary inference,
magnification, selective abstraction, personalization)
B. Schemas
1)
Consist of unspoken, inflexible assumptions or beliefs.
2)
Result from past (early) experience
3)
Form basis for screening discriminating weighing and coding stimuli
4)
Form basis for categorizing, evaluating experiences and making judgments
and distorting reality situations
5)
Determine content of cognitions formed in situations and the affective
response to them
6)
Increase vulnerability to depressions or relapse
Cognitive
Behavior Theories
Bandura
1. Decreased
self-reinforceing activities (overt and covert).
Costello
1. Loss of reinforcer
effectiveness results in generalized disruption of chains of behavior.
Seligman
1. Learned helplessness
results from belief in one's inability to effectively control positive
reinforcers.
2. Results from previous
experience of non-contingent positive or negative reinforcement schedules
Rehm
(Professor at UH)
1. Selective monitoring
of negative events; of immediate versus delayed consequences of behavior.
2. Stringent
self-evaluation criteria.
3. Insufficient
self-reward and excessive self-punishment.
4. Inaccurate
attributions of responsibility.
____________________________________________________________
HOW TO GET DEPRESSED
The major psychosocial causes of depression can be summarized
in the advice below. Of course, the point is that to avoid depression one
should do the opposite.
1) Pick your parents:
inherit a disposition to depression.
2) Lose a parent early in
life and have poor caretaking experiences following the loss
3) Learn to be critical of
self
4) Learn to expect little
from others
5) Learn to expect that
things will usually turn out badly
6) Learn to demand
perfection from self
7) Have many negative life
events
Lose spouse
Lose job
Lose cat
8) Have few social supports
Do not form close relationships
Avoid having friends
9) Take care not to do
things that will provide positive reinforcements for your efforts-- live
by the motto: nothing ventured is good enough.
10) Give up active exercise
11) Try not to laugh
____________________________________________________________
Does Loss of Parent During
Childhood Cause Depression?
There is a general belief, part of the conventional
wisdom, that losing a parent early in life predisposes a person to depression.
There is a great deal of research on this matter and some of the problems are
summarized below.
The idea stems from Freud's paper, "Mourning and
melancholia," in which he suggests that parental loss is an important
antecedent to depression.
When this idea is tested, some research says,
"yes" and some says, "no." Why the discrepancy?
There are a number of research considerations:
Child's age at time of loss
Sex of parent
Sex of child
Relationship with parent
Availability of the extended family
Reason for the loss
Parent left family--desertion
Death
Cause of parent's death
Suicide
Brief illness
Long illness
Accident
Is loss a stressorr of a genetic disposition to
depression?
The British psychiatrist, Michael Rutter, has concluded that
"Early parental loss predisposes to depression only if it leads to
inadequate care of the children and to lack of emotional stability in the
family." Clearly, if loss of parent is assumed to be an explanation of
later depression in the offspring, the explanation by itself is too simple.
---------------------------------------------------------------------------------------------------------
Assessment
Obtaining an accurate diagnosis of
depression is not easy and too often it is done in a simplistic way. The
"gold standard" for obtaining a diagnosis is the structured interview
which leads one though a series of questions and observations. These interviews
are often used in research, but are rarely used in clinical practice. For this,
and for much of research, professionals turn to other procedures. The tests
used traditionally in psychology, the Rorschach Inkblots and TAT are poor
diagnostic instruments for depression. Another widely used instrument, the
MMPI, is good. However, most researchers adopt specially developed instruments
such as the Beck Depression Instrument (see Burns book, Feeling Good,
for a copy of the questionnaire with scoring procedures) which is used in
psychotherapy research, the Hamilton which is more often used in drug research,
or one of about 10 other measures. They tend to have many of the same items,
but vary in whether they ask for a response in terms of how intense the
depressive feelings are or how often they have occurred in a specified period
of time. Some are self-report and others require that the professional go
through them item by item. There are special instruments for use with people
who have schizophrenia, or are elderly. Others are for children and
adolescents. Given this abundance of different measuring instruments one is
inclined to think that the experts really are not very clear on what depression
is. Certainly there are serious questions. Is the depression that is associated
with the loss of a loved on the same as the depression that simply appears
without special stress or trauma?
---------------------------------------------------------------------------------------------------------
Treatment of
Major Depression
Medical Treatment
The textbook has an excellent review
of this treatment and I will not repeat it here. I will only add a few things.
Anti-depressant medication is extremely popular in American society. A few
years ago, Prozac was on of the top-selling drugs of all. It was ahead of
medications for heart disease, asthma, etc. The newer anti-depressants, such as
Prozac, Paxil and Effexor, have been touted as revolutionary. However, as you
can see in textbook Table 7.7 they are not more effective than the tricyclics
they were intended to replace and which are much less expensive. Then it was
said that they have fewer side effects and are more tolerable. This is also not
true; they are about the same. There is another problem: most of the
anti-depressive medications are only marginally better than placebo (an inert
substance that looks like a medicine). Still another problem: relapse rates are
high when people stop taking the medications. They are also high for
psychotherapy.
Some forms of depression, those that
include psychotic symptoms such as hearing he voice of the devil telling one
that one is sinful, are resistant to conventional treatment. A recent discovery
(New York Times, 10/22/02) may be helpful on this. Preliminary results show
that Mifeprex (mifipristone), also known as RU-486, eases severe depression.
The drug was developed to end pregnancies and does this blocking the action of
progesterone. Taking the drug in much larger doses has an effect on cortisol
and cortisol may be directly associated with delusions and hallucinations. More
research using double-blind methods and larger samples is necessary.
St Johns Wort (hypericum) is
mentioned in the text as a remarkable drug in that it is a natural herb, and
not the product of a pharmaceutical manufacturer. Does it treat depression
effectively? In the USA we have the results of only one clinical trial and its
results were inconclusive given that neither hypericum nor a standard
anti-depressant drug were better than placebo (JAMA, 2002, 287,
1807-1813). However, the trials have been conducted many times in Germany and
the results are consistent. In a major study (Philipps,1999, British Medical
Journal, 319, 1534-1538) hypericum and imipramine were both significantly
better than placebo, but hypericum was a little better than imipramine. The herb does alleviate depression about as
well as the standard anti-depressant drugs. Of course, it must be taken
consistently as described on the package wrapper. It remains to be seen whether
the apparent absence of side effects is really true. There may be effects from
continued taking of the drug that have not appeared as yet. Do not consider my
remarks as a recommendation or prescription for hypericum. I am a psychologist
and not a physician and I do not prescribe medication. If I were depressed and
short of money I would consider taking hypericum and following the advice
offered in Burns' book, Feeling Good.
Electroconvulsive therapy (ECT) is an effective
treatment, but is quite expensive, may cause lasting memory problems and may
not have long-lasting effects. ECT has a bad reputation owing to the apparently
(I say apparently because as a psychiatric aide who assisted in the
administration of ECT I know we tried to be as humane and careful as we could)
cruel form of administration in past years. Grand mal seizures were part of the
process. Now there is a possible alternative. Transcranial magnetic
stimulation(TMS) is being used to treat
severe depression. It does not cause a seizure and patients who are treated
with TMS are able to drive home from the doctor's office, or go on to work. It
does not work for all patients and the question of relapse is unresolved.
Psychosocial Treatments
As these are also very well reviewed in the textbook only
a few comments are needed. In the treatment of depression, the psychological
treatments are as good as or better than the medical treatments. They have
longer lasting effects.
The psychodynamic therapies continue to be in question.
There is some evidence that brief psychodynamic therapy, which is not very
different from interpersonal therapy, may be effective. It is clear that
traditional psychoanalysis is not to be used.
Therapy for Bipolar
Disorder
Until about 50 years ago, the only
effective treatment of bipolar disorder was electroconvulsive therapy. Patients
tended to dislike it, and often claimed that it had impaired their memory.
Actually, memory is impaired, but only briefly. Many studies have shown that
the effects are not permanent. 50 years ago lithium was found to have mood
stabilizing qualities. It was not adopted at first, mainly because it is a
simple salt (there is much in El Paso water) and pharmaceutical companies could
not make money on it. It is highly effective and most patients with bipolar
disorder take it. However, it is toxic if lithium blood levels are elevated and
so blood tests must be taken from time to time. No one knows why it is
effective, but it may act on the neurotransmitter glutamate. Too little
glutamate is associated with depression, and too much is associated with mania.
Somatic Therapies
Lithium is commonly
used.
Anti-convulsants
Several drugs that were developed to
quiet seizure activity have been found to be effective for some people who have
bipolar disorder. These are typically used after trying lithium.
Tegratol
Depanoate
New Anti-convulsants
Topiramate
Lamotrigine
Gabapentin
Electroconvulsive
Therapy (ECT)
In addition, in the psychotic phase
of mania, anti-psychotic medications such as Haldol or Melleril, or the newer
drugs, risperidone, olanzapine, or ziprazadone are used.
Psychological
Therapies
Bipolar disorder has been neglected
by the research community and there is not much in the literature about
effective psychosocial therapies. The neglect is, in part, due to the
difficulty of working with bipolar patients. They tend to drop out of
treatment. They break appointments. They say they don't need help, they feel
great. This insistence on their well-being is actually a part of the disorder.
Insight into the illness is impaired. They have lost touch with the point of
view of others and cannot see themselves as others see them. Despite these
problems, there is enough in the research literature to go on, and the message
is clear: psychosocial treatment is important, but for bipolar disorder it is
secondary to medical treatment. Its main contribution may be that it improves
compliance with medical treatment.
Cognitive Behavioral
There is some evidence that
individual therapy is effective in reducing relapse for bipolar patients. It is
also effective in improving adherence to prescribed medication, and it helps
the patient deal with guilt associated with misbehavior during manic episodes.
It should be understood that when
the textbook says, on page 227, that family therapy was added to a drug regime,
and that better results were obtained, that the family therapy was cognitive
behavioral. Often when the term "family therapy" is used it refers to
systemic or strategic therapy, and they are quite different from CBT, and also
are ineffective with bipolar patients. Behavioral family therapy, also called,
family psychoeducation, emphasizes having a family resource group, assessment
by the family, and training in communication and problem-solving skills.
Bibliotherapy
Bad health insurance, or none at
all? No money for psychotherapy?
Consider bibliotherapy. That is, doing it by the book. Jamison and Scogin
(1995) found with 80 people who had mild to moderate depression that following
the exercises described in a book by David Burns, Feeling good, 1980,
available in paperback, that bibliotherapy was more effective than a
no-treatment control group. The reading group went from depressed to not
depressed and the control group did not change.
Support Groups
There are two major support groups
for people with affective disorders. One is NAMI, and you have the local chapters
of these. The website for the national office is www.nami.org. The other is the
National Depressive and Manic-Depressive Association (NDMDA). There are many
chapters in Houston. See the website at www.ndmda.org.
DIFFERENCES BETWEEN BIPOLAR AND UNIPOLAR DISORDERS
Bipolar Unipolar
Manic episodes present No manic episodes
Strong genetic Weaker genetic predisposition
Earlier onset Later onset
No sex difference More common in women
Sleep more May be sleep
impaired
Medications:
lithium Anti-depressants
anticonvulsants
Prevalence low Prevalence high
Suicide
There are a number of myths about suicide:
1.
People who discuss suicide will not commit the act.
2. Suicide is committed without warning.
3. Only people of a certain class commit
suicide.
4. Membership in a particular religious group
is a good predictor that a person will not commit suicide.
5. The motives for suicide are easily
established.
6. All who commit suicide are depressed.
7. A person with a terminal illness is
unlikely to commit suicide.
8. To commit suicide is insane.
9. A tendency to commit suicide is inherited.
10. Suicide is influenced by the seasons,
latitude, weather fronts, barometric pressure, humidity, precipitation,
cloudiness, wind speed, temperature, and days of the week.
11. Suicide is influenced by cosmic factors
such as sunspots and phases of the moon.
12. Improvement in emotional state means
lessened risk of suicide.
13. Suicide is a lonely event.
14. Suicidal people clearly want to die.
It seems odd that so many false
beliefs have developed about suicide. Perhaps it is because the topic remains
essentially taboo.
Prediction from
Psychological Tests
There has been some success in using measures
of rigidity of thinking as a predictor of suicide , but that is about all. The
results of psychological tests do not predict who will commit suicide.
Suicide Prevention
There is little evidence
of successful prevention of suicide. Researchers are now looking for settings
where suicide attempts are relatively high. One such place is in jails.
Although there are standards for screening and identifying prisoners who are at
risk for suicide, and when these are followed, suicide attempts are low, many
jailers do no follow the guidelines.
High schools are also being studied
as potential prevention sites. Youngsters would be screened with depression
screening tests and those with high scores would receive counseling.
____________________________________________________________
Effective Treatments of
Depression
Classic
Studies of Psychotherapy for Depression
1st Study
RUSH, BECK, KOJACK, HOLLON (1977)
PATIENTS: RANDOMLY ASSIGNED
15 MALE 11
THERAPISTS
26 FEMALE
18-65 YEARS OLD
41 DEPRESSED PATIENTS
COGNITIVE PHARMACOTHERAPY
11 WEEKS TREATMENT--AVERAGE
OUTCOME
1. BOTH TREATMENTS REDUCED DEPRESSION
2. 79% IN COGNITIVE THERAPY SHOWED MARKED IMPROVEMENT
3. 23% IN PHARMACOTHERAPY SHOWED MARKED IMPROVEMENT
4. COGNITIVE THERAPY HAD A LOWER DROP OUT RATE
2nd Study
MACLEAN
AND HAKSTIAN (1979)
14 THERAPISTS
BECK SCORE >23
20-60 YEARS OLD
72% FEMALE
196 DEPRESSED PATIENTS
BEHAVIOR PSYCHOTHERAPY PHARMACOTHERAPY ATTENTION
THERAPY PLACEBO
SOCIAL SKILLS INSIGHT AMITRIPTYLINE RELAXATION
ASSERTIVENESS CATHARSIS
DECISION MAKING SUPPORT
TREATMENT:
8-18 OUTPATIENT SESSIONS
WEEKLY
SPOUSES INVITED
OUTCOME
NORMAL BECK SCORE
50% 25% 25% 0%
DROPOUT
5%
30%
36% 26%
SOCIAL FUNCTIONING
BEST
WORST
MOOD
BEST
WORST
OVERALL RANK
1 3 2 4
These two studies clearly demonstrated that cognitive
therapy was effective in the treatment of depression. Since then there have
been many more, and they have also shown effectiveness of psychotherapy.
Study 3
Rosello and Bernal
1999
Patients: 71 Puerto Rican
Adolescents
Therapists: Advanced
graduate students
Conditions
Cognitive Interpersonal Wait List
Behavior
Therapy
Control
Therapy
Sessions 12 12 0
End
of
Treatment
Depression
Symptoms Medium Low High
Follow-up
Symptoms Low Medium Not Available
Drop-out 16% 17% 22%
This study does indicate that
therapies developed in the States with Euro-American and African-American
clients, work as well with Hispanic clients. It is interesting that
interpersonal therapy was best in the short-term, but that CBT did better over
the longer-term.