Explanation and Example
Depressive disorders describe a heterogeneous group of eight chronic, recurrent mental conditions characterized by depressed mood, distorted thinking and behavior, and impaired physical health (Fekadu, Shibeshi, & Engidawork, 2017). Depression is a unipolar mood disorder, where the patient suffers from depressive episodes but not mania. Related affective states include disappointment and despair. Diagnosable subtypes of this condition are diverse; one example is the major depressive disorder (MDD) where the patient shows symptoms of dysphoria, fatigue, anorexia, etc. (Fekadu et al., 2017).
Clinical depressive disorders are characterized by emotional, behavioral, somatic, and cognitive symptoms. The patient experiences sleep difficulties, fatigue, anorexia, suicidal ideation, etc. (Oltmanns & Emery, 2015).
The DSM-5 criteria for MDD diagnosis require five or more clinical episodes, chief among them being either depressed mood or diminished interest in day-to-day roles lasting for a minimum period of two weeks (American Psychiatric Association [APA], 2013). The other diagnostic symptoms may be significant weight loss, insomnia, psychomotor retardation, fatigue, and affective states of recurrent guilt, indecisiveness, and suicidal ideation. Further, the episodes must affect social functioning and should not be induced by substance use or clinical condition, e.g., schizophrenia (APA, 2013). The criteria exclude a history of mania or hypomania, except in substance-induced or comorbid cases.
Course and Outcome
Depressive episodes often start at age 30 onwards; however, episodic frequency and length vary between patients (Oltmanns & Emery, 2015). They last for two weeks or more after onset. An individual can experience up to six episodes in his/her lifespan. MDD is the most frequent and severe condition characterized by a period of symptom remission that is followed by relapse. Recovery occurs typically six months after the onset of the episode (Oltmanns & Emery, 2015). Symptom exacerbation can be avoided by keeping off from depressive environments or agents.
The World Health Organization [WHO] (2017) estimates that about 322m people (2.4% of the global population) have depressive disorders. The prevalence rates differ by gender, age, and region. The WHO (2017) estimates indicate that depression is higher in women than in men (5.1% vs. 3.6%), lowest in the Western Pacific (2.7% in males), and highest in Africa (5.9% in females). In the US, the prevalence rate stands at 5.9% (WHO, 2017). Depression is more common in older adulthood (7.5% in women aged >55 years) than in children. Further, the current lifetime prevalence of MDD is higher than the pre-World War II rate, at 14-17% (WHO, 2017).
The etiology of depressive disorders has social, psychological, and biological foundations. These stressors play a role in the onset and maintenance of unipolar depression. The primary social causes include stressful life events, such as interpersonal or job loss, marital problems, failure to meet goals, etc. (Oltmanns & Emery, 2015). Psychological factors, such as cognitive distortions or biases and feelings of hopelessness, can also contribute to symptom onset. The biological causes implicated in the etiology of unipolar depression include genetics (serotonin transporter gene), endocrine dysfunction, and HPA axis activation (Oltmanns & Emery, 2015).
Symptom severity can be managed through cognitive therapy that helps alter maladaptive schemas, somatic therapy, and interpersonal therapy to improve social skills and communication. Antidepressants like selective serotonin reuptake inhibitors (SSRIs) can improve remission. SSRIs, e.g., Fluoxetine, prevent serotonin reabsorption after release, resulting in optimal neurotransmission that is required to avoid the etiology of depression (Oltmanns & Emery, 2015). Other useful depressants include tricyclics, e.g., Amitriptyline, and monoamine oxidase inhibitors.
Suicidal ideation is the ninth symptom of criterion A of the DMS-5 diagnosis for depressive symptoms. A depressed patient experiences persistent thoughts of dying or self-destruction that goes beyond the fear of death (APA, 2013). He/she may lack an elaborate plan for killing oneself but may also involve suicide attempts.
Explanation and Example
Cyclic drops and rises in energy and mood characterize bipolar disorders (BDs) (Oltmanns & Emery, 2015). For example, a patient with at least one manic-like event and depressive event either suffers from either bipolar I disorder (BD-1) or bipolar II disorder (BD-2), depending on symptom severity. The distinguishing feature of BDs from depressive disorders is the presence episodic mania or hypomania in the patient. However, depression is the primary symptom. Patients may suffer from a full manic episode or its less severe subtype, hypomanic event.
The symptoms associated with mania include high energy, sleeplessness, and detachment. On the other hand, depressive episodes are associated with dampened spirits, disinterest in day-to-day activities, suicidal thoughts, etc.
Symptom severity determines BD diagnosis. For BD-1, the diagnostic criteria involve over one instance of short-term mania and depressive episodes, while that for BD-2 include episodic hypomania with inadequate symptoms and major depression (APA, 2013). An alternative diagnosis is a cyclothymia that encompasses hypomanic events and multiple depressive episodes occurring within two years that do not meet the two criteria (APA, 2013). An individual may also be diagnosed with rapid cycling if he/she experiences >4 mood episodes, resulting in reduced treatment outcomes.
Course and Outcome
The average onset age is 18 and 25 for BD-1 and BD-2, respectively (APA, 2013). A manic episode can last for up to three months. After the initial period, the course of BD tends to be sporadic and periods of exacerbated manic or depressive symptoms. BD patients often experience mood cycles of variable lengths. Although sustained recovery is possible, in some cases, the individual exhibits severe impairment.
The prevalence of BD in American adults (>18 years) is 2.8% (WHO, 2017). Gender variation is not significant; 2.8% and 2.9% of women and men in the US suffer from BD. On average, the lifetime prevalence is 4.4% (WHO, 2017). Further, this disorder affects about 2.9% of adolescents aged 13-18 years. It is more prevalent in girls than in boys (3.3% vs. 2.6%) (WHO, 2017).
BD is a multifactorial disorder with no specific causal agent. However, genetic factors and environmental influences are associated with an elevated BD risk (Oltmanns & Emery, 2015). Depression is often present in most patients with this disorder. It is the primary symptom accompanying a manic episode and an element of the diagnostic criteria. Suspected BD usually implicates a family history of the illness, alcohol abuse, risky behavior, and social or lifestyle stresses (Oltmanns & Emery, 2015). Thus, BD’s etiology may be related to social, psychological, or biological factors.
Pharmacological treatment of BD symptoms is possible through the monitored-use of lithium carbonate (Oltmanns & Emery, 2015). Unresponsive patients can receive carbamazepine or valproate to manage acute mania. These drugs are effective for treating a manic-depressive episode, but they come with side effects like nausea, vomiting, etc. (Oltmanns & Emery, 2015). In addition to medications, psychotherapy – CT and interpersonal therapy – can be an effective intervention for managing BD. In some inpatient settings, electroconvulsive therapy has been used to treat this disorder.
Suicidal ideation exists in BD patients due to the depressive episodes. In the DSM-5 diagnostic criteria, a depressed mood in BD cases is characterized by “recurrent thoughts of death or suicide” (APA, 2013, p. 298). However, a manic episode alone does not lead to suicidal behavior or attempt. Therefore, the suicide risk is highest during the cyclic depressive period.
American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: APA.
Fekadu, N., Shibeshi, W., & Engidawork, E. (2017). Major depressive disorder: Pathophysiology and clinical management. Journal of Depression and Anxiety, 6(1), 1-7.
Oltmanns, T. F., & Emery, R. E. (2015). Abnormal psychology (8th ed.). Upper Saddle River, NJ: Prentice Hall.
World Health Organization [WHO]. (2017). Depression and other common mental disorders: Global health estimates. Geneva: WHO.