CHAPTER 6: BIPOLAR AND DEPRESSIVE DISORDERS
• Opening vignette: Linda’s cluster of signs and symptoms (social withdrawal, lack of energy and interest, loss of
appetite, insomnia, irritability, and restlessness, constitute the disorder, Major Depressive Disorder.
• Bipolar and Depressive disorders consist of several different conditions characterized by various degrees of
depressed (low) or manic (high) moods.
• People with these syndromes have physical, emotional, and cognitive symptoms that may interfere with
their ability to work, study, sleep, eat, interact with others, have sexual relations, and enjoy daily life.
• Although most of us have mood fluctuations from time to time, major depressive disorder is not the same as a
transient “blue” mood or sad feelings, and mania is not the same as being elated.
What are Bipolar and Depressive Disorders?
6.1 Distinguish between normal sad mood and depression and between euphoria and mania.
• Bipolar and depressive disorders are syndromes whose predominant feature is a disturbance in mood.
• The disturbance can take the form of mood that is abnormally low- depression-or abnormally high- mania.
• Two categories:
1) Bipolar and Related Disorders – primary ones consist of: bipolar I , bipolar II, and cyclothymic disorder
each of which is characterized by both highs and lows in mood
2) 2) Depressive Disorders – primary ones include: disruptive mood dysregulation disorder, major depressive
disorder, persistent depressive disorder (dysthymia), and premenstrual dysphoric disorder. These
presentations are only marked by low mood only.
• The disorders are distinguished from each other by the presence of depressed or elated mood (or both) and by
the length of time or the specific times that the mood abnormalities persist.
Bipolar and Related Disorders
• Mood disturbance – too low or too high (mania). Elated mood - excitement and good feelings naturally match a
happy or an enjoyable experience. Mania – high mood that is clearly excessive and often accompanied by
inappropriate and potentially dangerous behaviour, irritability, pressure or rapid speech, and a false sense of well-
• Manic episodes almost always occur in tandem with episodes of depression, and a person who has only a single
manic episode will very likely have depression as well.
• Generally, a person is said to suffer from bipolar disorder (formerly known as manic-depressive disorder) when
both episodic depressed mood and episodic mania are present.
• Bipolar disorder consists of dramatic shifts in mood, energy, and ability to function. It is a LT episodic illness in
which mood shifts between the two emotional poles of mania and depression.
• In a depressed period, a person may be all but immobile, feeling unable to get out of bed.
• In a manic period, the same person may be so full of energy as to try to start a new business, buy a
house, and plan a trip around the world on the same day.
• At either extreme, the person cannot cope with the demands of everyday life.
• Periods of normal feelings (euthymia) and energy commonly occur between these mood changes.
• Commonly characterized as either bipolar I or bipolar II; the main difference is the degree of mania.
• Bipolar I: full-blown mania alternated with episodes of major depression; it also includes a single manic
episode with or without periods of depression.
• Bipolar II: hypomania alternated with episodes of major depression. Hypomania is a mood elevation that is clearly abnormal but not as extremely elevated as
In such a state, a person may be overly talkative, excitable, or irritable, but there are no
impulsive acts or gross lapses of judgment that are common during mania.
It is a “mild mania” and lasts at least 4 days.
Bipolar II is more common and is defined by having at least one episode of major depression
and at least one hypomaniac event. It can be especially difficult to diagnose because a
person experiencing hypomania may associate these episodes with periods of high
productivity or creativity and are less likely to report their symptoms as distressing or
• The frequency of mood elevations varies considerably across individuals and even within the same individual
across time. Shifts come out of the blue and are not necessarily in response to environmental events. Can occur
yearly or less frequently.
• In contrast, persons with Rapid Cycling Bipolar Disorder have four or more severe mood disturbances within a
single year. Even less common is an extremely rapid cycling pattern in which multiple shifts between manic and
depressed mood occur within a single day.
• People who have symptoms of mania and depression at the same time suffer from a mixed state; symptoms can
include agitation, insomnia, changes in appetite, psychosis, and suicidal thoughts. In such a state, a person can
feel very sad and very energized at the same time.
• Bipolar disorder requires lifelong maintenance treatment and clinical mgmt. Even though some are symptom free
between episodes, others have continuing symptoms (even when controlled by meds people report mild-to-
moderate residual symptoms). Others, despite treatment, have chronic, unremitting symptoms.
• In literature, bipolar disorder is frequently depicted as the mental illness that rests between the boundaries of
creativity and madness although this is not accurate.
• Cyclothymic Disorder – characterized by fluctuations that alternate between hypomanic and depressive
symptoms. The episodes are not as severe as with mania or major depression, but they persist for at least 2 years
and as a result of the cyclical and often unpredictable mood changes, cause impairment.
• Much less common than major depression, bipolar disorder affects approx 1% of North Americans over their
• The average age of onset of the first manic or depressive episode is 18.2 years.
• The disorder is unrelated to sex, race/ethnicity, family income and is commonly comorbid with substance use
disorders, anxiety disorders, and impulse control disorders.
Sex, Race, and Ethnicity
• The risk of developing bipolar I is fairly equal across the sexes, although bipolar II may be more common in
• Whereas whites tend to be diagnosed with bipolar disorder, African American individuals are more likely to receive
a diagnosis on the schizophrenia spectrum. Whether this diagnostic difference is accurate or reflects racial
variations affecting clinical presentation and expression of symptoms, access to care, help-seeking behaviours,
and clinical judgment remains unknown.
Developmental Factors in Bipolar Disorder
• Children: symptoms may be very different from adults. Mania may be chronic rather than episodic, may cycle
rapidly, or may appear as mixed state. During a manic episode, they are more likely to display irritability and
temper tantrums rather than a euphoric “high”.
• These symptoms make it difficult to distinguish this disorder from other conditions such as ADHD, conduct
disorder, oppositional defiant disorder, or even schizophrenia. Accurate diagnosis is critical because the
onset of bipolar disorder in childhood or early adolescence may represent a different and possibly more
severe condition than the condition that develops in adulthood. • Adults: 1% over the age of 60 report bipolar disorder. After that age, manic and depressive symptoms often
develop in association with medical illness, especially stroke. Older patients who may have had some elements of
mania in younger years can experience manic symptoms later in life. Intervals between mania and depression are
shorter and the episodes longer than among younger patients.
• Considerable medical and psychological comorbidity risk and often the effects are bidirectional.
• The comorbid conditions may increase risk for developing bipolar disorder, and bipolar disorder (or its
pharmacologic treatments) might increase the risk of some of the comorbid conditions.
• People are often at risk for thyroid disease, migraine headaches, heart disease, diabetes, and obesity.
• Substance abuse is also common; they might try to self-medicate with drugs or alcohol, which may trigger or
exacerbate manic or depressive episodes, or a third underlying trait (e.g., impulsivity) may contribute to both
• Other common comorbid psychological conditions are anxiety disorders, eating disorders, and attention deficit
Major Depressive Disorder
6.2 Understand the differences between bipolar I and bipolar II disorder and between major depressive disorder and
persistent depressive disorder.
• Core symptom: a persistent sad or low mood that is severe enough to impair a person’s interest in ability to
engage in normally enjoyable activities.
• in adults: depressed mood is central
• in children: persistent mood disturbance may take the form of irritability or hostility
• Can be extremely debilitating in part because of other psychological, emotional, social, and physical problems that
often accompany the persistent depressed mood.
• People often feel completely worthless or extremely guilty, and they may be at risk for harming
• Physically: disrupts sleep, appetite, and sexual drive. About 40% of people actually sleep and eat more
than usual (referred to as “atypical depression”). These changes can lead to major problems with
attention and concentration and can increase an already overwhelming sense of inadequacy and
inclination to withdraw from the world.
• It is an episodic illness; during their lifetime, people only have one episode (single episode), but often others
suffer from multiple episodes separated by periods of normal mood (recurrent).
• Quite prevalent: 7-18% of the US pop experiences at least one episode by age 40.
• A single episode may last at least 2 weeks, but often episodes can persist for several months.
• Must affect the person’s ability to function in social or work settings.
• Symptoms may result from physical disorders such as Cushing’s syndrome (too much cortisol hormone) and
hypothyroidism (lack of sufficient thyroid hormone); however, depression is not diagnosed if the symptoms are
caused by medical conditions such as these. Nor is the diagnosis made if the depressed feelings result from a life
event such as the death of a loved one.
• Depression can occur even after events that are not typically associated with sadness, such as after having a
Persistent Depressive Disorder (Dysthymia)
• A chronic state of depression.
• Symptoms are the same as those as major depression, but less severe. • It is the consistent persistence of depressed mood. By definition, persistent depressive disorder lasts 2 or more
years, and the individual is never without symptoms for more than 2 months.
• Although on a day-to-day basis, the symptoms are typically milder than those of major depressive disorder and
because they are so persistent, they may lead to severe outcomes (social isolation, high suicide risk) that affect
not only the sufferer but also extended family and friends.
• Since symptoms are less severe than major depression, people can suffer for years without seeking treatment.
Meanwhile, friends and family may turn away, often mislabelling the person as too moody and difficult.
• People with persistent depressive disorder may also have major depressive episodes (double depression).
• The combination of episodic major depressive episodes superimposed on chronic low mood is often
associated with poorer LT outcome and higher relapse risk than either disorder alone.
• In many cases, persistent depressive disorder is undiagnosed until the person has a major depressive episode.
When the person seeks help for the more severe depressive symptoms, the longer history of dysthymia is
Disruptive Mood Dysregulation Disorder (DMDD)
• A new disorder, making its first appearance in the DSM-5 and is controversial.
• Reserved for children aged 6-18 who have “severe recurrent temper outbursts that are grossly out of proportion in
intensity or duration to the situation.”
• Arguments for its inclusion are to slow the rate of diagnoses of childhood bipolar disorder which was being
overdiagnosed in children with disruptive tendencies.
• Arguments against its inclusion are that most children who receive this diagnosis already fit diagnostic criteria for
other childhood disorders and there is poor reliability in the diagnosis across clinicians.
• The harshest critics fear that this category is simply turning temper tantrums into a mental illness.
Premenstrual Dysphoric Disorder (PMDD)
• Afflict 3-8% of women of reproducing age.
• Follows a cyclical pattern and typically begins in the lat luteal phase of the menstrual cycle.
• Mood symptoms can vary and include deep sadness or despair, anxiety and tension, anger or irritability, or panic.
• Changes in sleep, appetite, and libido can also emerge.
• Not only affects sufferers, but can have significant effects on interpersonal relationships which can be vulnerable
to the extremes of emotionality often associated with the disorder.
Major Depressive Disorder with Peripartum Onset
• As many as 80% of new mothers develop the “baby blues” within a few days of childbirth.
• These mild symptoms (tearfulness, sadness, mood swings, irritability, and fatigue) generally subside 2 weeks
postpartum (after childbirth).
• Although transient for many mothers, “baby blues” are a risk factor for the development of postpartum depression.
• The prevalence of depression with onset in the first 6 months postpartum ranges from 6.5-12.9% across studies,
peaking at 2 months and 6 months after delivery.
• Not only does it negatively affect mothers’ functioning but also is associated with temperamental, social,
emotional, cognitive, and behavioural difficulties in children,
• In rare cases, women may suffer a condition known as postpartum mood episodes with psychotic features.
• Major depressive disorder is the most common psychiatric disorder in the US. 16.2% of people over 18 years.
Median age of onset is 30 years. • Dysthymia is less common, affecting approximately 2.5% of the population.
• Depression ranks fourth in terms of the global burden of disease. Disease burden uses an indicator called
Disability Adjusted Life Years (DALY), which measures the total amount of healthy life lost to all causes whether
from premature death or disability.
People with depression reported a fivefold increase in the time away from work than people
Sex, Race, and Ethnicity
6.3 Discuss sex differences in the risk for major depressive disorder
Depression in Women
- Across cultures, almost twice as many women as men suffer from major depressive disorder, but the exact ratio
changes with time.
- Depressive symptoms are more common among women who have few financial resources, are less education,
and are unemployed.
- Even among women, rates of depression vary by age. Reproductive events like puberty, the premenstrual period,
pregnancy, the postpartum period, and menopause all are risks for mood disturbances, suggesting that the ebb
and flow of female hormones may have some role.
Depression in Racial and Ethnic Minorities and Across Cultures
- In the US, white experience higher rates of major depressive disorder than non-Hispanic black and Hispanic pops.
- The two factors, ethnic identity and religious participation, seem to function as protective factors, lowering risk for
- A more fundamental question is whether the concept of depression is based primarily on a European (western)
understanding of mental illness. Many languages and cultures do not have words for depression, so simple
translations of western interview questions can complicate the diagnosis process, yielding inaccurate diagnosis
and incorrect prevalence data.
- Overall, individuals from various cultures tend to report both psycho and physical symptoms of depression.
Primary age-band of risk for depression is between 18-34 with the median of onset around 30 years.
Occurs across all ages, and the risk of depression in children, adolescents, people with chronic illnesses, and
older people (esp those with health problems) is increasing.
Although diagnostic criteria are the same, observable signs of depression may differ, and young people may lack
the necessary vocabulary and insight to describe depressed mood.
Warning signs: headaches, muscle aches, stomach-aches, or tiredness; school absence or poor performance;
unexplained irritability; crying spells; boredom; social withdrawal; alcohol or substance abuse; anger or hostility;
relationship difficulties; and reckelessnes.
If untreated, depression in adolescence can lead to school failure, alcohol or other drug use, and suicide.
Childhood: boys and girls are equally to have it. Around 13, rates begin to climb for girls but remain constant or
even decrease for boys. Late adolescence, the 2:1 ratio is established and thereafter remains constant.
Hormones, self-consciousness about bodily changes during puberty, poor sense of competence, socioeconomic
disadvantage, victimization, chronic life stressors, low self-esteem, and higher reactivity to stress. Any or all of
these may converge to both increase risk and perpetuate mood disturbances in women.
In addition to female sex, high neuroticism is also associated with depression.
Depression often goes unrecognized and untreated in children and adolescents. Early onset depression often
persists, recurs, and continues into adulthood. Only 10.6% of those over 60 suffer from depression and approx 1.3% suffer from persistent depressive
Older adults are also more likely to suffer from medical illness. Both the medications used to treat them can
complicate the detection and diagnosis of depression.
Depression may co-occur with many medical conditions, including cardiovascular disease, central nervous system
diseases, cancer, and migraines.
Coronary heart disease often coexists with depression, and depression can influence outcome from coronary
Can also exits with psychiatric conditions – nearly ¾ ppl with lifetime major depressive disorder had at least one
additional disorder including anxiety disorders, substance use disorder, and impulse control disorders.
Depression is also the most common comorbid disorder in eating disorders and often persists even after recovery
from eating disorders.
In most cases, depression occurred before the other conditions.
Twin studies examine how the same genetic and environmental factors can contribute to two different disorders.
The genetic coorelation between major depressive disorder and GAD is 100%, suggesting that the same genetic
factors influence the risk for both disorders.
Genes provide vulnerability to a negative mood state, and the environment shapes which negative mood state
emerges. This conclusion, that depression and anxiety represent the same gene(s) but different environments, is
one compelling explanation for why these two disorders co-occur so commonly.
Ranks as the 12hleading cause of death in the US.
WHO, nearly one million die from suicide; mortality rate of 19 per 100,000 globally.
Around the world, they have increased by 60% in the past 45 years,
Commonly believed that suicide rates are underreported due to the misclassification of cause of death in
situations such as single-vehicle car accidents.
Rates differ across the world; highest rates found in Belarus, Lithuania, and the Russian Federation.
Suicidal Ideation, Suicide Attempts, and Completed Suicide
Suicidal Ideation – thoughts about suicide can take different forms:
- passive ideation is a wish to be dead but does not include active planning about how to carry it out.
- active ideation includes thoughts about how to commit it, where, when, and how.
Acts are evaluated on lethality and intent.
Para-suicides are behaviours such as superficial cutting of the wrists or overdoses of nonlethal amounts of meds- acts
unlikely to result in death whether known or unknown.
Violent attempts such as hanging, self-inflicted gunshot wounds, and jumping from buildings are always associated
with serious intent.
Previous attempts at suicide increase the risk of suicide 30-40 times.
A history of deliberate self-harm is the strongest predictor of future suicidal behaviour.
Who Commits Suicide?
6.4 Discuss factors associated with suicide and the relationship between depression and suicidal ideati