Mood Disorders: Depression, Mania, & Bipolar Disorder

What is Mood?

Mood is a a conscious state of mind or predominant emotion

Websters Dictionary

What is a Mood Disorder? Involves disabling disturbances in emotions that are markedly different from normal functioning

Can also include cognitive & behavioral disturbances

Generally occurs in discrete episodesDepression extreme sadness Mania extreme elation and irritability

Types of Mood DisordersMain Distinction: unipolar or bipolarUnipolar: only one end of the emotion spectrumMajor Depressive EpisodeManic EpisodeBipolar: cycling between both ends of the emotion spectrum Bipolar Disorder

Other DisordersDysthymia: mild, chronic form of depression Cyclothymia: similar to bipolar, but a more mild form of mania (hypomania)

Bipolar DisordersBipolar I DisorderBipolar II DisorderCyclothymic Disorder

Manic Episode: DSM Criteria A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

During the period of mood disturbance, three (or more) 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 (e.g., feels rested after only 3 hours of sleep)(3)more talkative than usual or pressure to keep talking (4)flight of ideas or subjective experience that thoughts are racing(5)distractibility (i.e., attention too easily drawn to unimportant stimuli)(6)increase in goal-directed activity or psychomotor agitation(7)excessive involvement in pleasurable activities that have a high potential for painful consequences

Manic Episode Rule-Outsdo not meet criteria for a Mixed Episode Mixed episode = both manic and depressed nearly everyday for at least one week

marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder

Bipolar I 1 or more manic episodes; may have had past depressive episodes or not

Lifetime Prevalence: about 1%; equal in men and women

Course and Prognosis: poorer prognosis than MDD45% have one more episode only 50-60% achieve control over Sx with lithium40% develop a chronic disorder

Bipolar IIrecurrent major depressive episodes with hypomanic episodesHypomania - All the criteria of a Manic episode except criterion C (marked impairment)NOT full-blown manic episodes, if an individual does experience a manic episode, they are then diagnosed with Bipolar I Disordermatter of differential diagnosis

Bipolar DisorderBipolar IAlternation of full manic and depressive episodesAverage onset is 18 yearsTends to be chronicHigh risk for suicideBipolar IIAlternation of Major Depression with hypomaniaAverage onset is 22 yearsTends to be chronic10% progess to full biploar I disorder

CyclothymiaFor at least two years (one year for children and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major DepressionDuring a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a timeNo evidence of MDD or Manic episode during the first two years of disturbanceNo psychotic disorderNo organic cause

Mania Etiologybetter-suited for the biological model not normally distributed in the population Symptoms are very marked and severe

not necessarily precipitated by a positive life event & can override negative events further evidence in favor of diathesis

Familial Pattern seen

Twin and adoption studies

What Does Mania Look Like? Client 1: Mary

Depressive DisordersMajor Depressive Disorder (single, recurrent)[Major Depressive Disorder: Postpartum onset]**Dysthymic DisorderDouble DepressionPostpartum depression as a specifier

What Does Depression Look Like? SadnessSuicidal ThoughtsTirednessBoredomUnwilling to get out Insomnia

Depressive Episode/Disorder: DSM Criteria Five or more of the following during the same 2-week period that represent a change from usual functioning including either (1) depressed mood or (2) loss of interest.

Sad, depressed mood, most of the day, nearly every day for two weeksLoss of interest and pleasure in usual activitiesDifficulties sleepingShift in activity level Changes in appetite and weight loss/gainLoss of energy, fatigueNegative self-concept, self-blame, guilt, worthlessnessDifficulty concentrating Recurrent thoughts of death or suicide

Depression Diagnosis Rule-OutsThe symptoms do not meet criteria for a Mixed Episode

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Major DepressionMDD, Single episodeAbsence of mania or hypomaniaMDD, Recurrent2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood

Dysthymic Disorder: SymptomsDepressed/irritable moodPresence of two of the following:Appetite disturbanceSleep disturbanceLow energy/fatiguePoor concentration of difficulties making decisionFeelings of hopelessnessC. Present for two year period (one year in children and adolescents)D. No evidence of a Major Depressive Epidsode during the first two years (one year for children)E. No manic or hypomanic episodeF. No chronic psychotic disorderG. Not related to organic factors

Double DepressionNot a diagnosisMeet diagnostic criteria for both MDD and Dysthymic Disorder

PrevalencePoint prevalence is the percentage of the population who have the disorder at a particular time or over a given period of time.

Lifetime prevalence is the percentage of individuals who have ever had a specific disorder at any time.

Facts About Depression Major depression is the single most common psychiatric disorder in the U.S. The point prevalence rate over a 1-year period is 8% for men and 13% for women. Lifetime prevalence rate is 12.7% for men and 21.3% for women. In addition, depression is the most common factor leading to suicide.

What Does Depression Look Like? Client 1: Mary Client 2: Barbara Client 3: Evelyn

Video Reactions? What symptoms of depression did you notice in these clients?

Any evidence of suicidal thoughts?

Which patient might be more likely to commit suicide? Why?

Etiology: BiologicalGenetic FactorsFamily, twin, and adoption studies suggest that depression in hereditary More severe the depression in an individual, more likely that relative have depression as well MDD concordance: 40% MZ, 10% DZMania concordance: 75% MZ, 25% DZSeverity of disorder is due to strength of genetic loading

Etiology: Biological cont.Adoption studies More mood disorders occur in the biological relatives of those with mood disordersboth unipolar and bipolar disordersseverity linked to the strength of the genetic loading

Etiology: Biological ContNeurochemical FactorsNeurotransmittersNorepinephrineSerotoninDopamineNot clear what processes are dysfunctional (production, reuptake, chemical breakdown, etc.)Neuroendocrine changesHypothyroidisim

Research on Neurotransmittersnorepinephrine & serotoninImplicated in mania and depressioneffectiveness of antidepressants most drugs in psychiatry discovered by accidentNot as simple a relationship as previously thoughtE.g. TCA and MAOI drugsPermissive hypothesis

Becks Cognitive Theory of Depressiondistortions of reality & depressogenic cognitions result in depression

schema filters and organizes experiences to store beliefs and knowledge about ourselves

cognitive triad of negative schemasnegative view of the self, the world, and the future

Cognitive Theory Contnegative automatic thoughts further bias that individuals view of himself, the world, and the future e.g., arbitrary inference, selective abstraction, overgeneralization, magnification, etc.

thoughts focused on experiences of loss and failure

research supports the presence of distorted, automatic cognitions the causal relationship of these factors not established

Helplessness/Hopelessness ModelSeligmans learned helplessness model started as a conditioning model with dogs

those who were exposed to uncontrollable aversive situations would develop depression that was rooted in feelings of helplessness

Attributional ModelAbramson - Attribution of lack of control over stress leads to anxiety and depression

Cognitive distortions affect the interpretation of causes of events in peoples lives.

biased attributional style (i.e., a cognitive style regarding beliefs about the causes of events) characterized by internal, stable, and global attributions.

Seligman and BeckSeligmanAttributions are:InternalStableGlobal

I am inadequate (internal) at everything (global) and I always will be (stable).

Dark glasses about why things are bad

Interpretation (theory)BeckNegative interpretations about:ThemselvesImmediate world (their place)Future (their place)

I am not good at school (self). I hate this campus (world). Things are not going to go well in college (future).

Dark glasses about what is going on

Description

Attributional Model ContInternal - attribute negative events to own failingsStable - belief that causes of negative events remain constant Global - assume causes of negative events have broad and general effects

research supports the hopelessness model but cannot establish causal relationship

Major Depression: Social and Cultural FactorsStressful life eventsSocial support (marital relationship) (see chart)GenderCulture (see chart)

Marital Status and MDDPercentage w/MDD

Ethnicity and Prevalence of MDDPercentage by Ethnicity

Gender Differences in Depression Dr. Susan Nolen-HoeksemaWomen diagnosed twice as often as men difference not evident in childhoodboys and girls are just as likely to experience depressionChanges in preteen yearsWhat factors may be involved in the development of these differences?

Diathesis-Stress ModelNeither biological nor environmental and personal factors alone can produce depression a biological vulnerability (or diathesis) interacts with life stressors to produce depression For example, a neurotransmitter dysfunction may interact with life stressors (e.g., death of a loved one) to produce depression

Diathesis-Stress Example No Life EventLife Event DepressionLow NENormal NE

Comorbidity with Anxiety distinguishing depression from anxiety difficult

Watson & Clark: tripartite model

Negative affectivity (NA) - pervasive individual differences in negative emotionality and self-conceptCommon to anxiety & depression

Anhedonia - lack of experiencing pleasure specific to depression

Anxious arousal - physiological symptoms of anxiety specific to anxiety disorders

Psychological Treatments for Depression Psychodynamic Therapies

Cognitive-Behavioral TherapiesBeck Cognitive TherapySocial Skills TrainingBehavioral Activation

Interpersonal Therapy

Cognitive TherapyProcedures16 weeks of treatmentExtensive Assessment:Placebo & Clinical ManagementDepression Collaborative Research ProgramInterpersonal PsychotherapyTTreatment GroupsOutcome MeasuresDepressive SymptomsOverall symptomotology and life functioningFunctioning in treatment specific domainsResults:Post-TreatmentEquivalent success in three active treatments over placeboMedication was faster IPT better than CBT for more severely depressed patientsParticular treatments effected change in expected domainsResultsFollow-up-18 monthsEquivalent success in three active treatmentsOnly 20 to 30% of recovered patients were still wellPatients in IPT report more satisfaction with treatmentIPT and CBT patients more likely to report that treatment affected capacity to establish and maintain relationships and to understand source of their depressionMedicationImiprimineMany Controversial Issues

Biological Therapies for Depression Drug TherapiesTricyclicsSelective serotonin reuptake inhibitorsMonoamine oxidase inhibitorsElectroconvulsive Therapy

Mood Disorders: PrevalenceDisordersMajor DepressionDysthymiaBipolar IBipolar II

MDD (Postpartum)

Prevalence4.9%3.2%0.8%0.5

13%

Suicide8th leading cause of death in the U.S.Overwhelmingly white phenomenaSuicide rates also quite high in Native AmericanRate of suicide is increasing in adolescents and elderlyMales are more likely to commit suicideFemales are more likely to attempt suicide (except China)

5 Myths and Facts About SuicideMyth #1:People who talk about killing themselves rarely commit suicide.Fact:Most people who commit suicide have given some verbal clues or warnings of their intentions

5 Myths and Facts About SuicideMyth #2:The suicidal person wants to die and feels there is no turning back.Fact:Suicidal people are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems.

5 Myths and Facts About SuicideMyth # 3:If you ask someone about their suicidal intentions, you will only encourage them to kill themselves.Fact:The opposite is true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment.

5 Myths and Facts About SuicideMyth # 4:All suicidal people are deeply depressed.Fact:Although depression is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.

5 Myths and Facts About SuicideMyths # 5:Suicidal people rarely seek medical attention.Fact:75% of suicidal individuals will visit a physician within the month before they kill themselves.

Sociodemographic Risk FactorsMale> 60 yearsWidowed or DivorcedWhite or Native AmericanLiving alone (social isolation)Unemployed (financial difficulties)Recent adverse life eventsChronic Illness

Clinical Risk FactorsPrevious AttemptsClinical depression or schizophreniaSubstance AbuseFeelings of hopelessnessSevere anxiety, particularly with depressionSevere loss of interest in usual activitiesImpaired thought processImpulsivity

Assessing Risk and Planning Intervention

Commonalities of Suicide (Schneiderman, 1985)purpose is to seek a solution. goal is the cessation of consciousness (not death). stimulus is intolerable psychological pain. stressor is frustrated psychological needs. emotion is hopelessness-helplessness. cognitive state is ambivalence. perceptual state is constriction. action is egression. interpersonal act is communication of intention. consistency is with lifelong coping patterns.

Clinical Considerations of Suicide AssessmentFor those who are reluctant to assess suicide:

Asking questions may feel intrusive but not asking has dangerous consequencesA calm and genuinely concerned approach is effective

Suicide:TreatmentProblem-solving Cognitive behavioral therapyCoping skillsStress reduction

Postpartum Depression

BurdenIn the United States, depression is the leading cause of non-obstetric hospitalizations among women aged 18-44.

In the year 2000, 205,000 women aged 18-44 were discharged with a diagnosis of depression.

Seven percent of all hospitalizations among young women were for depression.

Perinatal Depression: Prevalence

Postpartum BluesMost common, 50-80%Relatively briefFew hours to several days Onset usually in first week to 10 days PPTypically remit spontaneously May represent the initial stages of PPD/PPP

Typical Blues SymptomsLow MoodMood LabilityInsomniaAnxietyCryingIrritability

Postpartum Psychosis Rare: 1/1000 postpartum women

Hallucinations and/or Delusions

Risk Factors:History Bipolar Affective Disorder/PsychosisFamily history of psychosisHaving first child

Aggressive intervention absolutely necessary

Postpartum Psychosis

Usually Begins Within 90 Days PostpartumLength is Quite VariablePrevalence: 1/500 to 1/1000Family history of bipolar disorder 33/1000Family history of postpartum psychosis 22/1000Personal history bipolar disorder: 1/2Sequelae: Future Postpartum Psychosis

Postpartum DepressionNot as mild or transient as the bluesNot as severely disorienting as psychosisRange of severityOften undetected

Postpartum Depression: Risk FactorsLower SES/unemploymentPast depression or anxiety disorderPast history of alcohol abuseStressful life-eventsPoor marital relationshipInadequate social supportChild-care related stressorsAfrican American ethnicity

Effects of Perinatal Depression:An Overview Depression negatively effects:

Mothers ability to motherMotherinfant relationshipEmotional and cognitive development of the child

Postpartum Depression:Maternal Attitudes

Infants perceived to be more bothersome

Make harsh judgments of their infants

Feelings of guilt, resentment, and ambivalence toward child

Loss of affection toward child

Postpartum Depression:Maternal Behaviors

Gaze less at their infants

Take longer to respond to infants utterances

Show fewer positive facial expressions

Lack awareness of their infants

Increased risk for abusing children

Postpartum Depression:Maternal Interactions

Flat affect, low activity level, and lack of contingent responding

OR

Alternating disengagement and intrusiveness

Effects of Maternal DepressionInfants- lowered Brazelton scores, frequent looking away, fussiness

Toddlers- poorer cognitive development, insecure attachment

Children- cognitive development of low ses boys

Adolescents-higher cortisol levels

What Can Be Done?

ROUTINE SCREENING

REFERRAL TO TREATMENT

Why Screen for Perinatal Depression? Screening is associated with increased detection

Georgiopoulos et al., 1999, 2001EPDS screening resulted in increased chart-based diagnosis of PPD from 3.7% to 10.7% after one year of universal screening Rochester, MN

Barriers to DetectionWomen will present themselves as well as they are ashamed and embarrassed to admit that they are not feeling happy

Media images contribute to this phenomena

Barriers to DetectionWomen will present themselves as well as they are ashamed and embarrassed to admit that they are not feeling happyTom Cruise: Snap out of it mentality

Media images contribute to this phenomena

Barriers to Detection (cont)Lack of knowledge about range of postpartum disorders

They dont want to be identified with Andrea Yeats

May genuinely feel better when you see them (they got dressed, out of house, lots of attention, not isolated)

I Was Depressed But Didnt Know It.Commonalities in the Experience of Non-depressed and Depressed Pregnant and Postpartum WomenChanges in appetiteChanges in weightSleep disruption/insomniaFatigue/low energyChanges in libido

What is Required for Effective Screening?What to do with a positive screen?Implement or refer for diagnostic assessmentArrange for treatmentAntidepressant medicationPsychotherapy (individual or group)Arrange for follow-up

People with bipolar disorder experience both the lows of depression and the highs of mania. Many describe their life as an emotional roller coaster. They sgift back and forth between exteme moods. People experiencing a manic episode rarely bring themselves in for treatment; they are often brought in by others.

Recurrent episodes create a downward spiral

Cyclothymic disorder is a more chronic version of bipolar disorder where manic and major depressive episodes are less severe. Such persons tend to remain in either a manic or depressive mood state for several years with very few periods of neutral mood. For the diagnosis, the pattern must last for at least 2 years (1 year for children and teens). Such persons are also at increased risk for developing Bipolar I or II disorder.Average age of onset is about 12 or 14 yearsCyclothymia tends to be chronic and lifelong.Most are female.Generally, the more severe the symptoms, the more you lean toward diathesis (medical model).Familial Pattern: 1st degree relatives of individuals w/Bipolar I have increased rates of Bipolar I (4-24%), Bipolar II (1-5%), and MDD (4-24%)--people with bipolar relatives are excluded from MDD studies. Twin and adoption studies provide strong evidence for Bipolar I Disorder.

Clinical Picture: Characterized by the presence of depressed/irritalbe mood that has persisted at learst 1 year. The main feature is annhedonia or the inaibity to experience plaeasure, social withdeqal, low self-esteem. It is interesting that these symptoms are not in the diagnostic criteria.

Dysthymic disorder shares many of the symptoms of major depressive disorder, butunlike MDD, the symptoms in dysthymia tend to be milder and remain relatively unchanged over long perods of tie, somethime as much as 20 to 30 years. During this time, the person cannot be symptom free for more than 2 months at a time. Many eventually experience a MDD episode at some point.Dysthymic disorder often develops first, and tis condition is asociated with problematic future course. Indeed many do not recover after two years, and relapse rates are very high.Double depression is very common with as many as 79% of those with dysthymia reporting a MDD epidode at some point in their lives.Even worse, patients with dysthymia were more likely than those with MDD to attempt suicide.These ideas were first supported by the effectiveness of antidepressants (most drugs in psychiatry discovered by accident) and then supplemented with additional evidence, effective TCA and MAOI drugs increase norepinephrine and serotonin for only a few days, then levels decrease to baseline, but depression is not relieved for at least 1 week (usually longer)Current thinking is that balance of the various neurotransmitters and their subtypes is more important than the absolute levels of any one nuerotransmitterPermissive hypothesis stipulates that when serotonin levels are low, other neurotransmitters are permitted to range more widely, become dysregularted and contribute to mood irregularities

Like Seligman, Aaron Beck believes that negative thinking lies at the heart of depression. According to Beck, maladaptive attitudes, a cognitive triad, errors in thinking, and automatic thoughts combine to procude the clinical disorder.

Maladaptive attitudes/negative schema: Beck believes that some people develop this negative schema as children, such as my general worth is tied to every task I perform or if I fail, others will feel repelled by me. This attitudes results from their own experience, their family relationships and the judgments of people around them.So for example in a self-blame schema individuals feel personally responsible for every bad thing that happens. With a negative self evaluation schema, they believe they can never do anything correctly.These thoughts are automatic according to Beck.Automatic: depressed people experience a steady train of unpleasant thoughts that keep suggesting to them that they are inadequate and their situation is hopeless.

According to the learned helpless theory of depression, people develop depression and anxiety when they assume that they have no control over life stress.This assumption is called a depressive attributional style.This style of thinking has three characteristics.Attribution is internal: in that one believes negative events are ones fault. (He does not like me because I have done something wrong)The attribution is stable: in that one believes that future negative events will be ones fault. If he leaves me it will be my fault because I was not good enough.Attribution is global in that the person believes negative events will influence many life activities. No one will ever want to go out with me.

The fact that both cognitive theorist have proposed three factors as part of their theories could lead to potential confusion. I thought if we examined them side by side, looked at the differences, we might eliminate the confusion.In Seligmans model the three characteristics describe the persons style of making attributions. So they tend to attribute negative events to their personal failings (internal). Seligman is more internal just about self: It is the thinking that causes the loss of sense of control. If you believe that you are inadequate at everything and always will be then you dont have much hope for controlling things.Negative glasses turned inward.

In contrast Beck focuses more on how people interpret thingsnot on how they account for things. It is a more outwardly focused theory. The first is very similar to Seligmanthey have negative interpretations of themselves (dark lenses looking inward) but the rest is really outwardly focused (dark lenses looking out at the world and the future).For example, someone who did poorly on an exam could say: I failed the exam because Im stupid (internal), I tend to fail exams in all of my classes (general), and I will always be a failure (stable).

Stressful life events: severe events precede all types of depression in studies (excpet for psychotic depressive). Major stress is a somewhat stronger predictor for initial episodes of depression.

Social support: depressed people tend to have less social support. A poor marital relationship in particular is a risk factor for depression.This deficiency in social support and difficult marital relationsips is liiely due to the fact that depressed people elicit negative reactions from others.This feature of depression has been studied in a veriety of ways, ranging from conducting telephone conversations with depressed patients, to listening to audiotapes of depressed patients, to aprticipating in face-to-face interactions. Data show that the behavior of depressed people elicits rejection.For example, the roomates of depresed college students rated social contacts with them as low in enjoyment and reported high levels of agreession toward them.Mildly dpressed college students were likely t be rejected by their roommates.What is it about the depressed person that elicit these negative reactions. Many find aversive things such as very slow speech, silences and hesitations, negative self-disclosures, negative affect, poor maintenance of eye contact and fewer positive facial expression as well as more negative facial expression. (come under emotion).More recent research has explored the idea that constant seeking of reassurance is particularly onerous to others. Depressed people seek reassurance that others truly care but even when reassured that are only temporaily satisfied. Their negative self-concept causes them to doubt the truth of the positive feedback, and their constant efforst to be reassured come to irritate others.Gender: Although bipolar disorders tend to be evenly divided between men and women, almost 70% of the individuals with major depressive disorder and dysthyymia are women. This discrepancy is constant around the world. However, rates of depression do seem to vary by ethnicity. Overall, rates are lower in African Americans and Hispanics. But for postpartum depression, this is not true about African Americans. Rates are higher. Also the rate is probably higher in Native Americans given the higher suicide rates.Source of generder difference: gender specific roles: women dependent and passive withch may put them at risk for depression by increasing/reinforcing their feelings of uncontrollability and helplessness.Andwomen tend to ruminate more about their situation where men tend to ignore their feelings and engate in activity to take their minds of their problems. This behavior may be therapeutic because activating people helps deprsssion.Culture:On the on hand, depression is a worldwide phenomenon; persons in all countries and cultures are at risk for it. On the other hand the precide picture of depresion varies from culture to cultureDepressed people in nonwestern countried tend to be troubled by physical symptoms such as fatigue, wweakness, sleep disturbances and weight loss. Depression in these countrieds is less often marked by psychological symptoms as self-blame and guildt.Percentage With Major DepressionResearchers were not able to distinguish depression from anxiety on the basis of psychological instruments (e.g., BDI, BAI).W & C developed the tripartite model to to explain the overlap between depression and anxiety

In 1977 the National Institute of Mental Health (NIMH) undertook a large, complex, and expensive three site study comparing Becks cognitive therapy, with Interpersonal Psychotherapy (IPT) and pharmocothertapy.This was the first multisite coordinated study initiated by the NIMH in the field of psychotherapy.It is widely cited and controversal.Tricylcic antidepressants are widely used treatments for depression and include imipramine (Tofranil) and amitriptyline (Elavil). It is not yet clear how these drugs work, but initially at least they block the reuptake of norepinephrine and other neurotransmitters. This process may take anywhere between 2 to 8 weeks and patients often feel worse and develop side effects before feeling better. Because of the side effects about 40% stop taking the drugs.Mao work by blocking an enzyme MAO that breakds down serotonin and norepinephrine. Are slight more effective than tricyclics and have fewer eside effects. However ingestion of some foods (cheese, red wine beer) can lead to severe hypertensive episodes and occasionally death.SSRIs specifically block the pre-synaptic reuptake of serotnin thius increasing levels of serotnin at the receptor site. Fouoxetine (Prozac) is the most popular SSRI. Risks of suicideo or acts of fiolence are no greater with Proazac than any other medication.St Johns Woprt is receiving increasing attention as n herbal solution for depression. Preliminary studies suggest that St. Johns Work works better than placebo in alleviating depression and works as well as low doses of other meidcations. It appears to have few side effects.

From Table 6.1 in Essentials text.Taken from Weissman et al 1991: Table labeld Lifetime prevalence of mood disorderSuicide is the eighth leading cause of death in the United States. Suicide is overwhelmingly a white phenomena and African Americans and Hispanics seldom commit suicide.Suicide rates are also quite high in Native Americans.

Recent adverse life events include loss or death of significant others, job loss, family history of suicideExample of article for intervention: Rudd, M. Stulman, D., Joiner, T. Dixon, W. (1996) Effectiveness of an Outpatient Intervention Targeting Suicidal Young Adults: Preliminary Results. Journal of Consulting and Clinical Psychology, 64, 1, 179-190.One successful approach with at risk teens included the above elements.Segre, Losch, OHara (submitted manuscript)

Being African-American is associated with a 31% increased risk compared to whites of endorsing an item indicating sad mood immediately after childbirth

The goal of reviewing these negative effects is to provide compelling evidence that screening for depression and referring depressed mothers to treatment is a legitimate concern for case managers. I hope to convince you that treatment of depression is essential to ensuring that children get a Healthy Start.While not every woman uses the 39 year old Catherine Oxenberg as a benchmark for her appearance, it is worth noting that women have a hard time escaping unrealistic images of themselves even in pregnancy.Reality for new mothers can be quite discrepant with these imagesMoms may feel: TiredAlone at home Lots of care for the babyOften there are other young children who need careNo time for self (cant even fit in a shower)Complete loss of control over time

Other symptoms such as loss of interest in activities, hyponchondriasis, and physical symptoms of anxiety can all be do to the rather normal course of pregnancy. We try to pay attention to clustering of symptoms, especially when depressed or low mood is present.