MOOD DISORDERS: AN

OVERVIEWCHAPTER 7

Introduction

Most of us feel depressed from time to time, but this is not depression.

Mood disorders – involve much more severe alterations in mood for much longer periods of time.

The disturbances of mood are intense and persistent and lead to serious problems in work and in relationships.

In 2000, depression ranked among the top five health conditions in the United States, ranking above heart disease and stroke.

The direct and indirect cost of depression is $83.1 billion within the U.S. This makes up 60% of the reported costs resulting from problems in the workplace.

Introduction

There are many types of depression recognized in the DSM-5.

These various types of depression used to be called affective disorders. This means extremes in emotion or affect – soaring elation or deep depression.

Having an abnormal mood is the main symptom.

Mood Disorders: An Overview The two key moods

involved in mood disorders are mania and depression.

Mania – means intense and unrealistic feelings of excitement and euphoria.

Depression – involves extremes of loneliness and dejection.

Normal mood states can occur between both types of episodes.

Types of Mood Disorders

Uni-polar Depressive Disorders – a person experiences only depressive episodes.

Bipolar Disorders – a person experiences both manic and depressive episodes.

There are noticeable differences in the symptoms, causal factors, and optimal treatments.

Severity – the number of dysfunctions experienced and the relative degree of impairment.

Duration – whether the disorder is acute, chronic, or intermittent.

Types of Mood Disorders

The most common form of mood episode that people present with is a major depressive episode. The person must be markedly depressed for most of the day and for most days for at least 2 weeks.

He or she must show at least 3 symptoms: feelings of worthlessness, guilt, thoughts of suicide, fatigue, physical agitation, changes in appetite, and sleep patterns.

Types of Mood Disorders

Manic episode – is when a person show a markedly elevated, euphoric, or expansive mood, often interrupted by occasional outbursts of intense irritability or even violence when people refuse to go along with the manic person’s wishes and schemes.

These extreme moods must persist for at least a week for this diagnosis to be made.

Three or more additional symptoms must occur in the same time period, ranging from behavioral symptoms (an increase in goal-directed activity), to mental symptoms where self-esteem becomes grossly inflated and mental activity may speed up (such as “flight of ideas” or “racing thoughts” to physical symptoms (such as a decreased need for sleep or psychomotor agitation).

Types of Mood Disorders

In milder forms, similar kinds of symptoms can lead to a diagnosis of hypomania episode – in which a person experiences abnormally elevated, expansive, or irritable mood for at least 4 days.

The person must have at least three other symptoms similar to those involved in mania, but to a lesser degree (e.g. inflated self-esteem, decreased need for sleep, flight of ideas, pressured speech, etc.). Hospitalization is not always required with this mental illness.

With all these illnesses there are varying degrees of causal pathways and treatments. Suicide tends to be a frequent outcome of significant depressions, both unipolar and bipolar.

The Prevalence of Mood Disorders

Major mood disorders occur with alarming frequency-at least 15-20 times for frequently than schizophrenia and at the same rate as all the anxiety disorders taken together.

Unipolar major depressive disorder (MDD), in which only major depressive episodes occur is the most common and has increased in the last couple decades.

Unipolar depression is always much higher for women than for men as are anxiety disorders. This is the same in most countries of the world. The few exceptions are Iran and Nigeria and this trend continues until about 65 years of age when it seems to disappear. Bipolar is less common.

Unipolar Mood Disorders

Feelings of depression are unpleasant when we are experiencing them, but they usually do not last long, dissipating on their own after a period of days or weeks or after they have reached a certain intensity level.

By slowing us down, mild depression sometimes saves us from wasting a lot of energy in the futile pursuit of unobtainable goals.

Depression is more common in people undergoing painful but common life events such as significant personal, interpersonal, or economic losses.

Loss and the Grieving Process

We tend to think of grief as the death of a loved one-a process that tends to be more difficult for men than for women.

There are usually 4 phases of normal response to the loss of a spouse or close family member: 1) numbing and disbelief, 2) yearning and searching for the dead person, 3) disorganization and despair that sets in when the person accepts the loss as permanent, and 4) some reorganization as the person gradually begins to rebuild his or her life. It is easy for a person to become stuck in one of the phases of grief.

Loss and the Grieving Process Grief can also follow

other events such as marital dissolution, unexpected economic misfortunes, or job loss.

If a person does not grieve these things, they may not be dealing with the issue at hand (at least at a psychological level).

Postpartum “Blues”

Normally, the birth of the child is seen as a happy event. Postpartum depression can sometimes occur with a new mother (and sometimes a new father) following the birth of a child. It can have negative effects on the new child.

Post partum depression was seen in the past as fairly common, but after more studies it has been shown that postpartum blues tend to be what happens.

The symptoms of postpartum blues include: changeable mood, crying easily, sadness, irritability, and mixed feelings of happiness. These feelings tend to occur within 50-70% of women within 10 days after the birth of their child and usually subside on their own.

It is very rare for women to have major depression with psychotic features. There is a likelihood of developing major depression after the postpartum blues, especially if the episode is severe. Hormonal readjustments and alterations in serotonergic and noradrenergic functioning may play a role in postpartum blues and depression. If the new mother has a lack of social support or has difficulty adjusting to her new identity and responsibilities, this may be higher. If the woman has a history of family depression the risk may be higher as well.

Dysthymic Disorder

When a mood disorder becomes a diagnosable mood disorder is up to clinical judgment that concerns the degree of impairment.

Dysthymic Disorder – is generally considered to be mild to moderate in intensity. A person must have a persistantly depressed mood most of the day, for more days than not, for at least 2 years.

2.5-6% of the population will have this disorder within their lifetime. The average duration of dysthymia is 4-5 years, but it can persist for 20 years or more.

Chronic stress has been shown to increase the severity of symptoms over a 7.5 year period.

Dysthymia tends to begin during the teenage years. 74% recover within 10 years , but 71% will relapse within 3 years.

Major Depressive Disorder

The diagnostic criteria for major depressive disorder means a person must have a major depressive episode and never have been manic, hypomanic, or have a mixed episode.

These persons must have a markedly depressed mood or a loss of interest in pleasurable activities most of every day, nearly every day, for at least 2 consecutive weeks.

The person must have 3 of the 4 symptoms: cognitive symptoms, feelings of worthlessness or guilt, and thoughts of suicide, fatigue of physical agitation, change of sleep, and/or change of appetite.

There is a high degree of people that have both depression and anxiety. The loss of contact with friends tends to happen quite a bit during depression. The person tends to be unmotivated to seek contact with their friends.

Depression as a Recurrent Disorder

When depression is diagnosed, it is specified whether it is a first-time or a recurrent episode.

The cause of depression with women tends to come from financially difficulties, severe stressful life events, and a high genetic risk.

Depressive episodes are usually time limited. The average untreated depression is about 6-9 months.

Chronic major depression has been associated with serious family problems and an anxious personality in childhood.

Most individuals may be able to get off the medication, but will relapse because of environmental issues.

Depression throughout the Life Cycle

Most unipolar depressive disorders most often occurs during late adolescence up to middle adulthood.

The incidence of depression rises sharply during adolescence. 15-20% of adolescents experience major depressive disorder at some point. This is when sex differences first begin to emerge.

Depression throughout the Life Cycle

Major depression that shows up in adolescence is very much likely to show up in adulthood.

Those individuals that live in nursing homes tend to have higher depression than those that continue to stay in their home.

Diagnosing older people can tend to be more difficult to diagnose because their symptoms overlap with other medical problems.

Specifiers for Major Depressive Episodes

One specifier is a major depressive episode with melancholic features. This happens when a person has lost interest in almost all activities. This tends to be more heritable than other forms of depression and is often associated with childhood trauma. These individuals tend to have significant cognitive impairment.

Psychotic symptoms (the loss of contact with reality and delusions (false beliefs) or hallucinations (false sensory perceptions), may rarely accompany major depression.

This is called a severe depressive episode with psychotic features. The mood congruent is generally negative in tone and may include: personal inadequacy, guilt, deserved punishment, death, or disease. Treatment tends to include antidepressants and antipsychotics.

Specifiers for Major Depressive Disorders

The other depressive issue involves atypical features. Major depressive episodes with atypical features include a pattern of symptoms characterized by mood reactivity; the person’s mood brightens in response to potential positive events.

Females tend to have atypical features with depression. They tend to have an earlier onset and are more likely to show suicidal thoughts. These individuals tend to respond to a different class of antidepressants – the monoamine oxidase inhibitors.

Specifiers for Major Depressive Disorders

Another specifier is used when the individual shows marked psychomotor disturbances. Major depressive episodes with catatonic features include a range of psychomotor symptoms, from motoric immobility as well as mutism and rigidity. Catatonic features are very common with depression.

Another specifier is shown with people that have recurrent major depressive episodes with a seasonal pattern, also known as seasonal affective disorder. The person must have had two episodes of depression in the past 2 years occurring at the same time of the year (most commonly fall and winter). Full remission tends to occur within the spring. This tends to be seen in higher latitudes and with younger individuals.

Causal Factors in Unipolar Mood Disorders

A variety of diseases and drugs can affect mood, leading sometimes to depression or to elevation or even mania.

Family studies have shown that the prevalence of mood disorders is approximately 2-3 times higher among blood relatives of persons with clinically diagnosed unipolar depression than in the population at large.

Twins studies have also shown a moderate genetic contribution. The estimates are substantially higher for more severe, early-onset, or recurrent depressions.

There is an even larger heritable link for families and bipolar disorder. Geneticists are still looking for genes concerning depression and bipolar disorder.

Neuro-chemical Factors

Since the 1960’s, researchers have concluded that neurotransmissions deal directly with depression. It was in the 1960’s and 70’s that researchers focused on two neurotransmitter substances of the monoamine class – norepinephrine and serotonin, because antidepressant medications seemed to have the effect of increasing these neurotransmitters availability at synaptic junctions.

This means that depression may originate from a lack of these neurotransmitters within the brain.

It has been concluded that no straight-forward mechanism could possibly be responsible for causing depression. Antidepressants do not seem to have much impact for 2-4 weeks.

Neuro-Chemical Factors

It was later figured out that dopamine played a significant role in depression including depression with atypical features and bipolar depression.

Since dopamine is involved with pleasure and reward, it would make sense concerning the symptoms.

In the last 20-25 years, scientists have focused on the complex interactions of neurotransmitters and how they affect cellular functioning. Neurotransmitters may have dysfunctions as they try to interact with some hormones or biological rhythms. Scientists question how these chemicals deal with too much stress within the body.

Neurophysiological and Neuroanatomical Influences

Researchers have found that damage to the left anterior prefrontal cortex often leads to depression. This takes place with brain damage to this area. Some individuals with depression may have a lowered activity in this portion of the brain.

When an EEG is administered to someone with depression, there is a lowered functioning or imbalance in one side of the brain as compared to the other. People with depression show a much lower activity in the left hemisphere of the brain. Similar findings have been shown with the PET scan.

Neurophysiological and Neuroanatomic Influences

Patients in remission from depression show the same type of hemisphere dominance as do children that are at risk for depression.

Prolonged depression also leads to decreased hippocampal volume, at least in older people with depression. This could be due to cell atrophy or cell death.

The amygdala, which is involved in perception of threat and in directing attention, tends to show increased activation in individuals with depression, which might be related to biased attention to negative emotional information.

Sleep

Sleep has 5 stages that occur in a relatively invariant sequence throughout the night. REM sleep (rapid eye movement) is characterized by rapid eye movements and dreaming as well as other bodily changes.

The first REM period does not usually begin until near the end of the first sleep cycle, about 75-80 minutes into sleep.

Patients who are depressed often show one or more of a variety of sleep problems, ranging from early morning awakening, periodic awakening during the night, and/or difficulty falling asleep. These changes occur in about 80% of hospitalized patients with depression and in about 50% of outpatients with depression.

Sleep

Research using EEG has found that patients with depression enter the first period of REM sleep after only 60 minutes or less of sleep and also show greater amounts of REM sleep during the early cycles than are seen in persons without depression.

The intensity and frequency of their rapid eye movements are also greater than in patients who are not depressed. This person tends to get lower than the amount of deep sleep present because REM has taken over.

Circadian Rhythms

Humans have a circadian rhythm (24 hour or daily) that includes cycles of sleep, including body temperature, propensity to REM sleep, and secretion of cortisol, thyroid stimulating hormone, and growth hormone.

Research has found some abnormalities in all of these rhythms in patients with depression, though not all patients show abnormalities in all rhythms.

Sunlight and Seasons

Another strange disturbance is seen in people with seasonal affective disorder, people being influenced by the total light in the environment.

A majority of these people become depressed in the fall and winter and normalize in the spring and summer.

Animals seem to have some of the same type of changes including: sleep changes, changes in activity levels, and appetite shifts.

Patients with Seasonal Affective Disorder tend to have increased appetite and sleep longer than usual. They tend to have circadian rhythms that are off. These people should use exposure to light (even artificial light), which can help to reestablish a rhythm.

Biological Explanations for Sex Differences

Hormonal factors such as normal fluctuations in ovarian hormones account for sex differences in depression.

This is only one of the causal associations that has not yet been discovered because of real methodological difficulties in conducting conclusive research on this topic.

For a small minority of women who are already at high risk, hormonal fluctuations may trigger depressive episodes, possibly by causing changes in the normal processes that regulate neurotransmitter systems.

Psychological Causal Factors – Stressful Events as Causal Factors

Psychological stressors are known to be involved in the onset of a variety of disorders, ranging from some of the anxiety disorders to schizophrenia, but nowhere has their role been more carefully studied than in the case of unipolar major depression.

These stressful events tend to be the loss of a loved one, serious threats to important close relationships or to one’s occupation or severe economic or serious health problems.

Separations through death or divorce are strongly associated with depression, although such losses also tend to precede other disorders such as panic disorder and generalized anxiety. Being a caretaker to someone with a major debilitating disease (such as Alzheimer’s) can be associated with the onset of both major depression and generalized anxiety disorder with the caretaker.

Stressful Events as Causal Factors

Sometimes, events that may have been at least partly generated by the depressed person’s behavior or personality are stressful, but can be the result of poor interpersonal problem solving.

Poor problem solving in turn leads to higher levels of interpersonal stress, which in turn leads to further symptoms of depression.

Another example is if a person does not pay their bills, they will have a variety of trouble. These can sometimes play an even stronger role in the onset of major depression.

Researchers have felt it important to create a process that can tell whether or not someone is depression and/or just perceiving their live events negatively.

Life events were reported and evaluators gave an average score of someone going through this life event. The score of participant are then compared. A woman whose husband left her for a younger woman would be more stressed out as compared to a woman that had moved on from a divorce to a new boyfriend.

Stressful Events as Causal Factors Individuals that are

having their first very stressful episode tend to be more depressed than people who have experienced reoccurring stressful events.

Mildly Stressful Events and Chronic Stress

Good studies have demonstrated that chronic stress is associated with increased risk for the onset, maintenance, and recurrence of major depression.

Different studies have used the term chronic stress (or chronic strain or difficulties) and the definition is one or more forms of stress ongoing for at least several months (e.g. poverty, lasting marital discord, medical disabilities, having a disabled child).

Vulnerability and Invulnerability Factors in Responses to Stressors

Women at genetic risk for depression not only experience more stressful life events, but also are more sensitive to them.

Personality and Cognitive Diatheses

Researchers have concluded that neuroticism is the primary personality variable that serves as a vulnerability factor for depression. This refers to a stable and heritable personality trait that involves a temperamental sensitivity to negative stimuli.

People that have high levels of this trait are prone to experiencing a broad range of negative moods, including not only sadness but also anxiety, guilt, and hostility.

Neuroticism is associated with a worse prognosis for complete recovery from depression.

High levels of introversion may also serve as vulnerability factors for depression, either alone or when combined with neuroticism.

Early Adversity as a Diathesis A range of adversities in the

early environment (e.g. family turmoil, parental psychopathology, physical or sexual abuse, and other forms of intrusive, harsh, and coercive parenting) can create both short-term and long-term vulnerability to depression.

There are individuals that have undergone early adversity and have remained extremely resilient.

Beck’s Cognitive Theory

Aaron Beck, a psychiatrist who became disenchanted with psychodynamic theories of depression early in his career, developed his own cognitive theory of depression.

Beck believed that cognitive symptoms of depression often precede and cause the affective or mood symptoms rather than vice versa. Example – if you think you are stupid and ugly, this may lead to depression.

Beck’s theory (a diathesis-stress theory) in which negative cognitions are central, has become somewhat more elaborate over the years while still retaining its primary tenets.

There tend to be underlying dysfunctional beliefs, known as depressogenic schemas, which are rigid, extreme, and counterproductive.

Beck maintained that simply having these dysfunctional beliefs – is sufficient to make someone depressed.

Beck’s Cognitive Theory

These depression-producing beliefs or schemas are thought to develop during childhood and adolescence as a function of one’s negative experiences with one’s parents and significant others. This creates a vulnerability to developing depression.

Negative automatic thoughts – thoughts that often occur just below the surface of awareness and involve unpleasant, pessimistic predictions.

Negative cognitive triad – 1) negative thoughts of the self, 2) negative thoughts about one’s experiences and the surrounding world, and 3) negative thoughts about one’s future.

These tend to include: all-or-none reasoning., selective abstraction (focusing on the negative detail of the situation instead of what was positive), and arbitrary inference – jumping to conclusion based on minimal or no evidence.

Studies have shown that cognitive behavioral therapy is very effective given depression.

The Helplessness and Hopelessness Theories of Depression

The learned helplessness theory of depression originated out of observations in an animal research laboratory. Martin Seligman first proposed that the lab phenomenon known as learned helplessness might provide a useful animal model of depression.

Seligman reported that lab dogs who were first exposed to uncontrollable shocks later acted in passive and helpless manners when they were in a situation where they could control the shocks.

This means that when animals or humans find that they have no control over aversive events (such as shock), they may learn that they are helpless, which makes them unmotivated to try to respond in the future. They show passivity and depressive symptoms. They are slow to learn that any response they may make is effective.

Depressed animals show lower levels of aggression, loss of appetite and weight, and changes in monoamine neurotransmitter levels.

The Reformulated Helplessness Theory

Abramson proposed that when people are exposed to uncontrollable negative events, they ask themselves why, and the kinds of attributes that people make are, in turn, central to whether they become depressed.

These investigators proposed three critical dimensions on which attributes are made: 1) 2) internal/external, global/specific, and 3) stable or unstable.

The Hopeless Theory of Depression Abramson proposed that having

a pessimistic attributional style in conjunction with one or more negative life events was not sufficient to produce depression unless one first experienced a state of hopelessness.

A hopelessness expectancy – was defined by the perception that one had no control over what was going to happen and by the absolute certainty that an important bad outcome was not going to occur.

The Rumination Response Styles Theory of Depression

When some people have depressed feelings, they tend to focus intently on how they feel and why they feel that way – a process called rumination.

Rumination involves a pattern of repetitive and passive mental activity. Those people that ruminate on a regular basis tend to have more depressive feelings.

Self-focused rumination leads to increased recall of more negative autobiographical memories, thereby feeding into a vicious cycle of depression.

Men are more likely to take part in distracting activity (or consume alcohol) when they get depressed. Teaching girls to distract themselves may help their mental health.

Lack of Social Support and Social-Skills Deficits

Women without a close relationship were more likely than those with at least one close confidant to become depressed if they experienced a severely stressful event.

Some people with depression have social skills-deficits.

Bipolar Disorders

Bipolar disorder is the presence of a major or hypomanic episode with a period of depression.

A person having a manic episode tends to feel elevated, euphoric, and has an expansive mood, which is often interrupted by occasional outbursts of intense irritability or even violence – especially when others refuse to go along with a manic person’s wishes and schemes.

These extreme moods must persist for at least a week for this diagnosis to be made. There must also be functioning impairment of occupational and social functioning, and hospitalization is often necessary during manic episodes.

Cyclothymic Disorder

Some individuals are subject to cyclical mood changes less severe than the mood swings seen in bipolar disorder. In the past, these were referred to as cyclothymic temperament or personality.

This disorder lacks certain extreme symptoms of bipolar disorder and lacks psychotic features such as delusions and marked impairment.

The mood is generally dejected, there is a loss of pleasure and activities and pastimes. There might also be low energy, feelings of inadequacy, social withdrawal, and pessimism.

There may be times of cyclothymia where a person becomes especially creative and productive because of increased physical and mental energy. There must be a two year period in which numerous periods with hypomanic and depressed symptoms are evident. These individuals are at-risk for developing full-blown bipolar I or II disorder.

Bipolar Disorders (I and II)

Bipolar I disorder – is distinguished from major depressive disorder by at least one manic episode or mixed episode.

A mixed episode – is characterized by symptoms of both full-blown manic and major depressive episodes for at least one week. These were once thought to be relatively rare but have been now reported as more common. The long-term outcome is not good for these individuals.

Bipolar Disorders (I and II)

Bipolar II disorder – experiences full-blown manic or mixed episodes but has experienced clear-cut hypomanic episodes as well as major episodes like bipolar I.

Bipolar II is more common than bipolar I. About 2-3% of the population has this.

Bipolar II disorder evolves into bipolar I in only 5-15% of cases, suggesting these disorders are distinct.

Bipolar Disorders (I and II)

Bipolar disorders occur equally in males and females. This disorder tends to begin in adolescence and/or early adulthood (with an average age of 18-22).

Most patients with bipolar disorder experience periods of remission with they are relatively symptom-free, although this may occur on only about 50% of the days. 20-30% tends to experience significant impairment and mood swings.

60% tend to have chronic occupational and/or interpersonal problems between episodes. Events can be seasonal in nature.

Bipolar Disorders (I and II)

75% of the time tends to be in a depressive state and 25% of the time tends to be manic.

There is a high overlap in symptoms of those with major depression and being depressed with having bipolar. People with bipolar tends to have more psychotic episodes, psychomotor retardation, and more substance abuse.

Those with unipolar depression tend to show more anxiety, agitation, insomnia, physical complaints, and weight loss.

Most individuals with bipolar are misdiagnosed with unipolar depression. The younger that someone is diagnosed, the more manic episodes that they are likely to have.

Bipolar Disorders (I and II)

Individuals with bipolar tends to have more depressive episodes than people with unipolar depression. Those individuals that have rapid cycling generally experience more than 4 episodes a year.

Luckily, rapid cycling tends to disappear within about 2 years.

Even with mood stabilizing medications, the probability of “full recovery” is discouraging.

There are definitely biological causes for bipolar disorder. Results from twin studies also show a biological inheritance tendency.

Serotonin tends to be low in both depressive and manic phases. Norepinephrine, serotonin, and dopamine are all involved in regulating our mood states. Lithium decreases dopamine activity and are antimanic.

Bipolar Disorder (I and II)

Stressful life events appear to be as important in precipitating bipolar depressive episodes and there is some evidence that stress may trigger manic episodes.

Many patients that suffer from mood disorders never seek treatment and even without formal treatment will recover.

More and more people with this disorder are seeking treatment as lost work and suffering are difficult to deal with.

There has been a decrease in psychotherapy and a steady rate of use of antidepressants. The social stigma of mental illness is also increasing.

About 40% of those that get treatment for bipolar are receiving adequate treatment.

Pharmacotherapy

Anti-depressant, mood stabilizing, and antipsychotic drugs are all used in treatment for unipolar and bipolar disorders.

The first category of antidepressants was developed in the 1950’s; these medications are known as monoamine oxidase inhibitors (MAOI’s) because they inhibit the action of monoamine oxidase – the enzyme responsible for breaking down nerepinephrine and serotonin once released. These drugs can have potentially fatal and dangerous side-effects if certain foods rich in the amino acid tyramine are consumed (e.g. red wine, beer, aged cheese, salami). They are not used very often today unless other medications have failed.

Pharmacotherapy

The drug treatment of choice since the early 1960’s until about 1990 was one of the standard antidepressants (called tricyclic antidepressants) because of their chemical structure, which are known to increase neurotransmission of the monoamines.

Only about 50% is there significant improvement. 50% of people do not respond to an initial trial of medication or a combination of medications.

Tricyclics have unpleasant side effects for some people (dry mouth, constipation, sexual dysfunction, and weight gain may occur). Most patients do not continue the drug long enough to see the advantages. These drugs are toxic when taken in large numbers.

Pharmacotherapy

Physicians tend to choose selective serotonin reuptake inhibitors (SSRI) even though they are no more effective than tricyclics. These medications tend to have less side effects, but are being overly prescribed.

In the past decade, a new atypical antidepressant have also become increasingly popular, and each has its own advantages. Bupropion (Wellbutrin) does not have many side effects (especially sexual side effects) as the SSRI’s, but helps people with depression that gain weight, have loss of energy, and oversleep.

Vanlafaxine (Effexor) seems superior to the SSRI’s in the treatment of severe or chronic depression.

The Course of Treatment with Antidepressant Drugs

Antidepressant drugs usually require at least 3-5 weeks to take effect. If there are no signs of improvement after about 6 weeks, physicians should try a new medication because 50% do not response to the first drug prescribed, but do to the second drug.

The natural course of untreated depression typically takes 6-9 months. Thus, when depressed patients take drugs for 3-4 months and then stop because they are feeling better, they are likely to relapse because their underlying symptoms are still present. More episodes of depression can happen while the person is still on the medication.

Lithium and other Mood-Stabilizing Drugs

Lithium therapy has become widely used as a mood stabilizer in the treatment of both depressive and manic episodes of bipolar depression.

Mood stabilizers have both anti-manic and anti-depressant effects.

Lithium – 75% of individuals taking this medication show at least partial improvement. Rapid cycling is less likely to happen if the person is taking antidepressants as well as Lithium. Some people take Lithium to prevent new episodes.

Lithium therapy can cause lethargy, cognitive slowing, weight gain, decreased motor coordination, and gastrointestinal disorders. Long-term use can lead to kidney malfunction and damage. Many people with bipolar tend to miss the feeling of manic episodes. If people can tolerate the side effects, it greatly minimizes the chance of suicide and successful suicide.

Electroconvulsive Therapy (ECT)

Antidepressants tend to take 3-4 weeks to produce significant improvement.

ECT is often used with severely depressed patients who may present with an immediate and serious suicidal risk, including those with psychotic features.

After about 6-12 treatments ) with treatments given every other day) the person tends to get better within 2-4 weeks. The treatment induces seizures are delivered under general anesthesia and with muscle relaxants. The most immediate side effect is confusion.

Suicide

The risk of suicide (taking one’s own life) is a significant factor in all types of depression.

50-90% of those that complete suicide do so during a depressive episode or in the recovery phase.

This tends to happen when the person begins to emerge in the recovery phase. Even when suicide is not associated with depression, it generally follows a different mental illness. Those with two or more mental disorders have a much higher risk of suicide.

3% of Americans have made a suicide attempt in their lives. 9% have experienced suicidal ideation. Most of these individuals do not really want to die and they usually attempt this alone. There is a long-lasting distress of those that are left behind.