What is Seasonal Affective Disorder?

Introduction

Seasonal affective disorder (SAD) is a mood disorder subset in which people who have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year, most commonly in winter. Common symptoms include sleeping too much and having little to no energy, and overeating. The condition in the summer can include heightened anxiety.

In the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and DSM-5, its status was changed. It is no longer classified as a unique mood disorder but is now a specifier, called “with seasonal pattern”, for recurrent major depressive disorder that occurs at a specific time of the year and fully remits otherwise. Although experts were initially sceptical, this condition is now recognised as a common disorder.

In the United States, the percentage of the population affected by SAD ranges from 1.4% of the population in Florida, to 9.9% in Alaska. SAD was formally described and named in 1984 by Norman E. Rosenthal and colleagues at the National Institute of Mental Health.

Brief History

SAD was first systematically reported and named in the early 1980s by Norman E. Rosenthal, M.D., and his associates at the National Institute of Mental Health (NIMH). Rosenthal was initially motivated by his desire to discover the cause of his own experience of depression during the dark days of the northern US winter. He theorised that the reduction in available natural light during winter was the cause. Rosenthal and his colleagues then documented the phenomenon of SAD in a placebo-controlled study utilising light therapy. A paper based on this research was published in 1984. Although Rosenthal’s ideas were initially greeted with scepticism, SAD has become well recognised, and his 1993 book, Winter Blues has become the standard introduction to the subject.

Research on SAD in the United States began in 1979 when Herb Kern, a research engineer, had also noticed that he felt depressed during the winter months. Kern suspected that scarcer light in winter was the cause and discussed the idea with scientists at the NIMH who were working on bodily rhythms. They were intrigued, and responded by devising a lightbox to treat Kern’s depression. Kern felt much better within a few days of treatments, as did other patients treated in the same way.

Signs and Symptoms

SAD is a type of major depressive disorder (MDD), and sufferers may exhibit any of the associated symptoms, such as feelings of hopelessness and worthlessness, thoughts of suicide, loss of interest in activities, withdrawal from social interaction, sleep and appetite problems, difficulty with concentrating and making decisions, decreased libido, a lack of energy, or agitation. Symptoms of winter SAD often include oversleeping or difficulty waking up in the morning, nausea, and a tendency to overeat, often with a craving for carbohydrates, which leads to weight gain. SAD is typically associated with winter depression, but springtime lethargy or other seasonal mood patterns are not uncommon. Although each individual case is different, in contrast to winter SAD, people who experience spring and summer depression may be more likely to show symptoms such as insomnia, decreased appetite and weight loss, and agitation or anxiety.

Bipolar Disorder

With seasonal pattern is a specifier for bipolar and related disorders, including bipolar I disorder and bipolar II disorder. Most people with SAD experience major depressive disorder, but as many as 20% may have a bipolar disorder. It is important to discriminate between diagnoses because there are important treatment differences. In these cases, people who have the With seasonal pattern specifier may experience a depressive episode either due to MDD or as part of bipolar disorder during the winter and remit in the summer. Around 25% of patients with bipolar disorder may present with a depressive seasonal pattern, which is associated with bipolar II disorder, rapid cycling, eating disorders, and more depressive episodes. Differences in biological sex display distinct clinical characteristics associated to seasonal pattern: males present with more Bipolar II disorder and a higher number of depressive episodes, and females with rapid cycling and eating disorders.

Cause

In many species, activity is diminished during the winter months in response to the reduction in available food, the reduction of sunlight (especially for diurnal animals) and the difficulties of surviving in cold weather. Hibernation is an extreme example, but even species that do not hibernate often exhibit changes in behaviour during the winter. Presumably, food was scarce during most of human prehistory, and a tendency toward low mood during the winter months would have been adaptive by reducing the need for calorie intake. The preponderance of women with SAD suggests that the response may also somehow regulate reproduction.

Various proximate causes have been proposed. One possibility is that SAD is related to a lack of serotonin, and serotonin polymorphisms could play a role in SAD, although this has been disputed.[20] Mice incapable of turning serotonin into N-acetylserotonin (by serotonin N-acetyltransferase) appear to express “depression-like” behaviour, and antidepressants such as fluoxetine increase the amount of the enzyme serotonin N-acetyltransferase, resulting in an antidepressant-like effect. Another theory is that the cause may be related to melatonin which is produced in dim light and darkness by the pineal gland, since there are direct connections, via the retinohypothalamic tract and the suprachiasmatic nucleus, between the retina and the pineal gland.[citation needed] Melatonin secretion is controlled by the endogenous circadian clock, but can also be suppressed by bright light.

One study looked at whether some people could be predisposed to SAD based on personality traits. Correlations between certain personality traits, higher levels of neuroticism, agreeableness, openness, and an avoidance-oriented coping style, appeared to be common in those with SAD.

Pathophysiology

Seasonal mood variations are believed to be related to light. An argument for this view is the effectiveness of bright-light therapy. SAD is measurably present at latitudes in the Arctic region, such as northern Finland (64°00′N), where the rate of SAD is 9.5%. Cloud cover may contribute to the negative effects of SAD. There is evidence that many patients with SAD have a delay in their circadian rhythm, and that bright light treatment corrects these delays which may be responsible for the improvement in patients.

The symptoms of it mimic those of dysthymia or even major depressive disorder. There is also potential risk of suicide in some patients experiencing SAD. One study reports 6-35% of sufferers required hospitalization during one period of illness. At times, patients may not feel depressed, but rather lack energy to perform everyday activities.

Subsyndromal Seasonal Affective Disorder is a milder form of SAD experienced by an estimated 14.3% (vs. 6.1% SAD) of the US population. The blue feeling experienced by both SAD and SSAD sufferers can usually be dampened or extinguished by exercise and increased outdoor activity, particularly on sunny days, resulting in increased solar exposure. Connections between human mood, as well as energy levels, and the seasons are well documented, even in healthy individuals.

Diagnosis

According to the American Psychiatric Association DSM-IV criteria, Seasonal Affective Disorder is not regarded as a separate disorder. It is called a “course specifier” and may be applied as an added description to the pattern of major depressive episodes in patients with major depressive disorder or patients with bipolar disorder.

The “Seasonal Pattern Specifier” must meet four criteria: depressive episodes at a particular time of the year; remissions or mania/hypomania at a characteristic time of year; these patterns must have lasted two years with no non-seasonal major depressive episodes during that same period; and these seasonal depressive episodes outnumber other depressive episodes throughout the patient’s lifetime. The Mayo Clinic describes three types of SAD, each with its own set of symptoms.

Management

Treatments for classic (winter-based) seasonal affective disorder include light therapy, medication, ionized-air administration, cognitive-behavioural therapy (CBT) and carefully timed supplementation of the hormone melatonin.

Light Therapy

Photoperiod-related alterations of the duration of melatonin secretion may affect the seasonal mood cycles of SAD. This suggests that light therapy may be an effective treatment for SAD. Light therapy uses a lightbox which emits far more lumens than a customary incandescent lamp. Bright white “full spectrum” light at 10,000 lux, blue light at a wavelength of 480 nm at 2,500 lux or green (actually cyan or blue-green) light at a wavelength of 500 nm at 350 lux are used, with the first-mentioned historically preferred.

Bright light therapy is effective with the patient sitting a prescribed distance, commonly 30-60 cm, in front of the box with her/his eyes open but not staring at the light source for 30-60 minutes. A study published in May 2010 suggests that the blue light often used for SAD treatment should perhaps be replaced by green or white illumination. Discovering the best schedule is essential. One study has shown that up to 69% of patients find lightbox treatment inconvenient and as many as 19% stop use because of this.

Dawn simulation has also proven to be effective; in some studies, there is an 83% better response when compared to other bright light therapy. When compared in a study to negative air ionization, bright light was shown to be 57% effective vs. dawn simulation 50%. Patients using light therapy can experience improvement during the first week, but increased results are evident when continued throughout several weeks. Most studies have found it effective without use year round but rather as a seasonal treatment lasting for several weeks until frequent light exposure is naturally obtained.

Light therapy can also consist of exposure to sunlight, either by spending more time outside or using a computer-controlled heliostat to reflect sunlight into the windows of a home or office. Although light therapy is the leading treatment for seasonal affective disorder, prolonged direct sunlight or artificial lights that don’t block the ultraviolet range should be avoided due to the threat of skin cancer.

The evidence base for light therapy as a preventive treatment for seasonal affective disorder is limited. The decision to use light therapy to treat people with a history of winter depression before depressive symptoms begin should be based on a persons preference of treatment.

Medication

SSRI (selective serotonin reuptake inhibitor) antidepressants have proven effective in treating SAD. Effective antidepressants are fluoxetine, sertraline, or paroxetine. Both fluoxetine and light therapy are 67% effective in treating SAD according to direct head-to-head trials conducted during the 2006 Can-SAD study. Subjects using the light therapy protocol showed earlier clinical improvement, generally within one week of beginning the clinical treatment. Bupropion extended-release has been shown to prevent SAD for one in four people, but has not been compared directly to other preventive options in trials.

Modafinil may be an effective and well-tolerated treatment in patients with seasonal affective disorder/winter depression.

Another explanation is that vitamin D levels are too low when people do not get enough Ultraviolet-B on their skin. An alternative to using bright lights is to take vitamin D supplements. However, studies did not show a link between vitamin D levels and depressive symptoms in elderly Chinese nor among elderly British women.

Other Treatments

Depending upon the patient, one treatment (e.g. lightbox) may be used in conjunction with another (e.g. medication).

Negative air ionisation, which involves releasing charged particles into the sleep environment, has been found effective with a 47.9% improvement if the negative ions are in sufficient density (quantity).

Physical exercise has shown to be an effective form of depression therapy, particularly when in addition to another form of treatment for SAD. One particular study noted marked effectiveness for treatment of depressive symptoms when combining regular exercise with bright light therapy. Patients exposed to exercise which had been added to their treatments in 20 minutes intervals on the aerobic bike during the day along with the same amount of time underneath the UV light were seen to make quick recovery.

Of all the psychological therapies aimed at the prevention of SAD, cognitive-behaviour therapy, typically involving thought records, activity schedules and a positive data log, has been the subject of the most empirical work, however, evidence for CBT or any of the psychological therapies aimed at preventing SAD remains inconclusive.

Epidemiology

Nordic Countries

Winter depression is a common slump in the mood of some inhabitants of most of the Nordic countries. It was first described by the 6th century Goth scholar Jordanes in his Getica wherein he described the inhabitants of Scandza (Scandinavia). Iceland, however, seems to be an exception. A study of more than 2000 people there found the prevalence of seasonal affective disorder and seasonal changes in anxiety and depression to be unexpectedly low in both sexes. The study’s authors suggested that propensity for SAD may differ due to some genetic factor within the Icelandic population. A study of Canadians of wholly Icelandic descent also showed low levels of SAD. It has more recently been suggested that this may be attributed to the large amount of fish traditionally eaten by Icelandic people, in 2007 about 90 kilograms per person per year as opposed to about 24 kg in the US and Canada, rather than to genetic predisposition; a similar anomaly is noted in Japan, where annual fish consumption in recent years averages about 60 kg per capita. Fish are high in vitamin D. Fish also contain docosahexaenoic acid (DHA), which help with a variety of neurological dysfunctions.

Other Countries

In the US, a diagnosis of SAD was first proposed by Norman E. Rosenthal, M.D. in 1984. Rosenthal wondered why he became sluggish during the winter after moving from sunny South Africa to (cloudy in winter) New York. He started experimenting increasing exposure to artificial light, and found this made a difference. In Alaska it has been established that there is a SAD rate of 8.9%, and an even greater rate of 24.9% for subsyndromal SAD.

Around 20% of Irish people are affected by SAD, according to a survey conducted in 2007. The survey also shows women are more likely to be affected by SAD than men. An estimated 3% of the population in the Netherlands suffer from winter SAD.

Book: Beating OCD and Anxiety

Book Title:

Beating OCD and Anxiety – 75 Tried and Tested Strategies for Sufferers and their Supporters.

Author(s): Helena Tarrant.

Year: 2020.

Edition: First (1st).

Publisher: Cherish Editions.

Type(s): Paperback and Kindle.

Synopsis:

Does anxiety impact on everything you do, leaving you unable to get through the day or with an inability to make decisions, no matter how small? Has it affected or even destroyed friendships and relationships? Or maybe you know or live with someone with these issues, and feel unable to help them?

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Written in accessible language, conveniently segmented and illustrated with over 100 original cartoons, the techniques are described clearly and concisely. Beating OCD and Anxiety knows you don’t want to read pages of complex theory on your quest for help.

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What is Mood Disorder?

Introduction

Mood disorder, also known as mood affective disorders, is a group of conditions where a disturbance in the person’s mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Mood disorders fall into the basic groups of elevated mood, such as mania or hypomania; depressed mood, of which the best-known and most researched is major depressive disorder (MDD) (commonly called clinical depression, unipolar depression, or major depression); and moods which cycle between mania and depression, known as bipolar disorder (BD) (formerly known as manic depression). There are several sub-types of depressive disorders or psychiatric syndromes featuring less severe symptoms such as dysthymic disorder (similar to but milder than MDD) and cyclothymic disorder (similar to but milder than BD). Mood disorders may also be substance induced or occur in response to a medical condition.

English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood-disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.

Refer to Depression (Mood).

Epidemiology

According to a substantial amount of epidemiology studies conducted, women are twice as likely to develop certain mood disorders, such as major depression. Although there is an equal number of men and women diagnosed with bipolar II disorder, women have a slightly higher frequency of the disorder.

The prevalence of depressive symptoms has increased over the years with recent generations reporting a 6% increase in symptoms of depression compared to individuals from older generations.

In 2011, mood disorders were the most common reason for hospitalization among children aged 1-17 years in the United States, with approximately 112,000 stays. Mood disorders were top principal diagnosis for Medicaid super-utilisers in the United States in 2012. Further, a study of 18 States found that mood disorders accounted for the highest number of hospital readmissions among Medicaid patients and the uninsured, with 41,600 Medicaid patients and 12,200 uninsured patients being readmitted within 30 days of their index stay – a readmission rate of 19.8 per 100 admissions and 12.7 per 100 admissions, respectively. In 2012, mood and other behavioural health disorders were the most common diagnoses for Medicaid-covered and uninsured hospital stays in the United States (6.1% of Medicaid stays and 5.2% of uninsured stays).

A study conducted in 1988 to 1994 amongst young American adults involved a selection of demographic and health characteristics. A population-based sample of 8,602 men and women ages 17-39 years participated. Lifetime prevalence were estimated based on six mood measures:

  • Major depressive episode (MDE) 8.6%.
  • Major depressive disorder with severity (MDE-s) 7.7%.
  • Dysthymia 6.2%.
  • MDE-s with dysthymia 3.4%.
  • Any bipolar disorder 1.6%.
  • Any mood disorder 11.5%.

Classification

Depressive Disorders

  • Major depressive disorder (MDD):
    • Commonly called major depression, unipolar depression, or clinical depression, wherein a person has one or more major depressive episodes.
    • After a single episode, Major Depressive Disorder (single episode) would be diagnosed.
    • After more than one episode, the diagnosis becomes Major Depressive Disorder (Recurrent).
    • Depression without periods of mania is sometimes referred to as unipolar depression because the mood remains at the bottom “pole” and does not climb to the higher, manic “pole” as in bipolar disorder.
  • Individuals with a major depressive episode or major depressive disorder are at increased risk for suicide.
  • Seeking help and treatment from a health professional dramatically reduces the individual’s risk for suicide.
  • Studies have demonstrated that asking if a depressed friend or family member has thought of committing suicide is an effective way of identifying those at risk, and it does not “plant” the idea or increase an individual’s risk for suicide in any way.
  • Epidemiological studies carried out in Europe suggest that, at this moment, roughly 8.5% of the world’s population have a depressive disorder. No age group seems to be exempt from depression, and studies have found that depression appears in infants as young as 6 months old who have been separated from their mothers.
  • Depressive disorder is frequent in primary care and general hospital practice but is often undetected.
  • Unrecognised depressive disorder may slow recovery and worsen prognosis in physical illness, therefore it is important that all doctors be able to recognise the condition, treat the less severe cases, and identify those requiring specialist care.

Diagnosticians recognise several subtypes or course specifiers:

  • Atypical depression (AD):
    • This is characterised by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (“comfort eating”), excessive sleep or somnolence (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
    • Difficulties in measuring this subtype have led to questions of its validity and prevalence.
  • Melancholic depression:
    • This is characterised by a loss of pleasure (anhedonia) in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
  • Psychotic major depression (PMD):
    • Or simply psychotic depression, is the term for a major depressive episode, in particular of melancholic nature, wherein the patient experiences psychotic symptoms such as delusions or, less commonly, hallucinations.
    • These are most commonly mood-congruent (content coincident with depressive themes).
  • Catatonic depression:
    • This is a rare and severe form of major depression involving disturbances of motor behaviour and other symptoms.
    • Here, the person is mute and almost stuporose, and either is immobile or exhibits purposeless or even bizarre movements.
    • Catatonic symptoms can also occur in schizophrenia or a manic episode, or can be due to neuroleptic malignant syndrome.
  • Postpartum depression (PPD)
    • This is listed as a course specifier in DSM-IV-TR; it refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth.
    • Postpartum depression, which affects 10-15% of women, typically sets in within three months of labour, and lasts as long as three months.
    • It is quite common for women to experience a short-term feeling of tiredness and sadness in the first few weeks after giving birth; however, postpartum depression is different because it can cause significant hardship and impaired functioning at home, work, or school as well as, possibly, difficulty in relationships with family members, spouses, or friends, or even problems bonding with the newborn.
    • In the treatment of postpartum major depressive disorders and other unipolar depressions in women who are breastfeeding, nortriptyline, paroxetine (Paxil), and sertraline (Zoloft) are in general considered to be the preferred medications.
    • Women with personal or family histories of mood disorders are at particularly high risk of developing postpartum depression.
  • Premenstrual dysphoric disorder (PMDD):
    • This is a severe and disabling form of premenstrual syndrome affecting 3-8% of menstruating women.
    • The disorder consists of a “cluster of affective, behavioural and somatic symptoms” that recur monthly during the luteal phase of the menstrual cycle.
    • PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders in 2013.
    • The exact pathogenesis of the disorder is still unclear and is an active research topic. Treatment of PMDD relies largely on antidepressants that modulate serotonin levels in the brain via serotonin reuptake inhibitors as well as ovulation suppression using contraception.
  • Seasonal affective disorder (SAD):
    • Also known as “winter depression” or “winter blues”, is a specifier.
    • Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving in spring.
    • The diagnosis is made if at least two episodes have occurred in colder months with none at other times over a two-year period or longer.
    • It is commonly hypothesised that people who live at higher latitudes tend to have less sunlight exposure in the winter and therefore experience higher rates of SAD, but the epidemiological support for this proposition is not strong (and latitude is not the only determinant of the amount of sunlight reaching the eyes in winter).
    • It is said that this disorder can be treated by light therapy.
    • SAD is also more prevalent in people who are younger and typically affects more females than males.
  • Dysthymia:
    • This is a condition related to unipolar depression, where the same physical and cognitive problems are evident, but they are not as severe and tend to last longer (usually at least 2 years).
    • The treatment of dysthymia is largely the same as for major depression, including antidepressant medications and psychotherapy.
  • Double depression:
    • Can be defined as a fairly depressed mood (dysthymia) that lasts for at least two years and is punctuated by periods of major depression.
  • Depressive Disorder Not Otherwise Specified (DD-NOS):
    • This is designated by the code 311 for depressive disorders that are impairing but do not fit any of the officially specified diagnoses.
    • According to the DSM-IV, DD-NOS encompasses “any depressive disorder that does not meet the criteria for a specific disorder.”
    • It includes the research diagnoses of recurrent brief depression, and minor depressive disorder listed below.
  • Depressive personality disorder (DPD)
    • This is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features.
    • Originally included in the DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R.
    • Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study.
  • Recurrent brief depression (RBD):
    • Distinguished from major depressive disorder primarily by differences in duration.
    • Individuals with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2-3 days.
    • Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle.
    • Individuals with clinical depression can develop RBD, and vice versa, and both illnesses have similar risks.
  • Minor depressive disorder:
    • Or simply minor depression, which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.

Bipolar Disorders

Bipolar disorder (BD) (also called “manic depression” or “manic-depressive disorder”), an unstable emotional condition characterised by cycles of abnormal, persistent high mood (mania) and low mood (depression), which was formerly known as “manic depression” (and in some cases rapid cycling, mixed states, and psychotic symptoms). Subtypes include:

  • Bipolar I:
    • This is distinguished by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes.
    • A depressive episode is not required for the diagnosis of Bipolar I Disorder, but depressive episodes are usually part of the course of the illness.
  • Bipolar II :
    • Consisting of recurrent intermittent hypomanic and depressive episodes or mixed episodes.
  • Cyclothymia:
    • This is a form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes.
  • Bipolar disorder not otherwise specified (BD-NOS):
    • Sometimes called “sub-threshold” bipolar, indicates that the patient has some symptoms in the bipolar spectrum (e.g. manic and depressive symptoms) but does not fully qualify for any of the three formal bipolar DSM-IV diagnoses mentioned above.

It is estimated that roughly 1% of the adult population has bipolar I, a further 1% has bipolar II or cyclothymia, and somewhere between 2% and 5% percent have “sub-threshold” forms of bipolar disorder. Furthermore, the possibility of getting bipolar disorder when one parent is diagnosed with it is 15-30%. Risk, when both parents have it, is 50-75%. Also, while with bipolar siblings the risk is 15-25%, with identical twins it is about 70%.

A minority of people with bipolar disorder have high creativity, artistry or a particular gifted talent. Before the mania phase becomes too extreme, its energy, ambition, enthusiasm and grandiosity often bring people with this type of mood disorder life’s masterpieces.[29]

Substance-induced

A mood disorder can be classified as substance-induced if its aetiology can be traced to the direct physiologic effects of a psychoactive drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Also, an individual may have a mood disorder coexisting with a substance abuse disorder. Substance-induced mood disorders can have features of a manic, hypomanic, mixed, or depressive episode. Most substances can induce a variety of mood disorders. For example, stimulants such as amphetamine, methamphetamine, and cocaine can cause manic, hypomanic, mixed, and depressive episodes.

Alcohol-Induced

High rates of major depressive disorder occur in heavy drinkers and those with alcoholism. Controversy has previously surrounded whether those who abused alcohol and developed depression were self-medicating their pre-existing depression. But recent research has concluded that, while this may be true in some cases, alcohol misuse directly causes the development of depression in a significant number of heavy drinkers. Participants studied were also assessed during stressful events in their lives and measured on a Feeling Bad Scale. Likewise, they were also assessed on their affiliation with deviant peers, unemployment, and their partner’s substance use and criminal offending. High rates of suicide also occur in those who have alcohol-related problems. It is usually possible to differentiate between alcohol-related depression and depression that is not related to alcohol intake by taking a careful history of the patient. Depression and other mental health problems associated with alcohol misuse may be due to distortion of brain chemistry, as they tend to improve on their own after a period of abstinence.

Benzodiazepine-induced

Benzodiazepines, such as alprazolam, clonazepam, lorazepam and diazepam, can cause both depression and mania.

Benzodiazepines are a class of medication commonly used to treat anxiety, panic attacks and insomnia, and are also commonly misused and abused. Those with anxiety, panic and sleep problems commonly have negative emotions and thoughts, depression, suicidal ideations, and often have comorbid depressive disorders. While the anxiolytic and hypnotic effects of benzodiazepines disappear as tolerance develops, depression and impulsivity with high suicidal risk commonly persist. These symptoms are “often interpreted as an exacerbation or as a natural evolution of previous disorders and the chronic use of sedatives is overlooked”. Benzodiazepines do not prevent the development of depression, can exacerbate pre-existing depression, can cause depression in those with no history of it, and can lead to suicide attempts. Risk factors for attempted and completed suicide while using benzodiazepines include high dose prescriptions (even in those not misusing the medications), benzodiazepine intoxication, and underlying depression.

The long-term use of benzodiazepines may have a similar effect on the brain as alcohol, and are also implicated in depression. As with alcohol, the effects of benzodiazepine on neurochemistry, such as decreased levels of serotonin and norepinephrine, are believed to be responsible for the increased depression. Additionally, benzodiazepines can indirectly worsen mood by worsening sleep (i.e. benzodiazepine-induced sleep disorder). Like alcohol, benzodiazepines can put people to sleep but, while asleep, they disrupt sleep architecture: decreasing sleep time, delaying time to REM sleep, and decreasing deep sleep (the most restorative part of sleep for both energy and mood). Just as some antidepressants can cause or worsen anxiety in some patients due to being activating, benzodiazepines can cause or worsen depression due to being a central nervous system depressant – worsening thinking, concentration and problem solving (i.e. benzodiazepine-induced neurocognitive disorder). However, unlike antidepressants, in which the activating effects usually improve with continued treatment, benzodiazepine-induced depression is unlikely to improve until after stopping the medication.

In a long-term follow-up study of patients dependent on benzodiazepines, it was found that 10 people (20%) had taken drug overdoses while on chronic benzodiazepine medication despite only two people ever having had any pre-existing depressive disorder. A year after a gradual withdrawal programme, no patients had taken any further overdoses.

Just as with intoxication and chronic use, benzodiazepine withdrawal can also cause depression. While benzodiazepine-induced depressive disorder may be exacerbated immediately after discontinuation of benzodiazepines, evidence suggests that mood significantly improves after the acute withdrawal period to levels better than during use. Depression resulting from withdrawal from benzodiazepines usually subsides after a few months but in some cases may persist for 6-12 months.

Due to Another Medical Condition

“Mood disorder due to a general medical condition” is used to describe manic or depressive episodes which occur secondary to a medical condition. There are many medical conditions that can trigger mood episodes, including neurological disorders (e.g. dementias), metabolic disorders (e.g. electrolyte disturbances), gastrointestinal diseases (e.g. cirrhosis), endocrine disease (e.g. thyroid abnormalities), cardiovascular disease (e.g. heart attack), pulmonary disease (e.g. chronic obstructive pulmonary disease), cancer, and autoimmune diseases (e.g. multiple sclerosis).

Not Otherwise Specified

Mood disorder not otherwise specified (MD-NOS) is a mood disorder that is impairing but does not fit in with any of the other officially specified diagnoses. In the DSM-IV MD-NOS is described as “any mood disorder that does not meet the criteria for a specific disorder.” MD-NOS is not used as a clinical description but as a statistical concept for filing purposes.

Most cases of MD-NOS represent hybrids between mood and anxiety disorders, such as mixed anxiety-depressive disorder or atypical depression. An example of an instance of MD-NOS is being in minor depression frequently during various intervals, such as once every month or once in three days. There is a risk for MD-NOS not to get noticed, and for that reason not to get treated.

Causes

Meta-analyses show that high scores on the personality domain neuroticism are a strong predictor for the development of mood disorders. A number of authors have also suggested that mood disorders are an evolutionary adaptation. A low or depressed mood can increase an individual’s ability to cope with situations in which the effort to pursue a major goal could result in danger, loss, or wasted effort. In such situations, low motivation may give an advantage by inhibiting certain actions. This theory helps to explain why negative life incidents precede depression in around 80% of cases, and why they so often strike people during their peak reproductive years. These characteristics would be difficult to understand if depression were a dysfunction.

A depressed mood is a predictable response to certain types of life occurrences, such as loss of status, divorce, or death of a child or spouse. These are events that signal a loss of reproductive ability or potential, or that did so in humans’ ancestral environment. A depressed mood can be seen as an adaptive response, in the sense that it causes an individual to turn away from the earlier (and reproductively unsuccessful) modes of behaviour.

A depressed mood is common during illnesses, such as influenza. It has been argued that this is an evolved mechanism that assists the individual in recovering by limiting his/her physical activity. The occurrence of low-level depression during the winter months, or seasonal affective disorder, may have been adaptive in the past, by limiting physical activity at times when food was scarce. It is argued that humans have retained the instinct to experience low mood during the winter months, even if the availability of food is no longer determined by the weather.

Much of what is known about the genetic influence of clinical depression is based upon research that has been done with identical twins. Identical twins have exactly the same genetic code. It has been found that when one identical twin becomes depressed the other will also develop clinical depression approximately 76% of the time. When identical twins are raised apart from each other, they will both become depressed about 67% of the time. Because both twins become depressed at such a high rate, the implication is that there is a strong genetic influence. If it happened that when one twin becomes clinically depressed the other always develops depression, then clinical depression would likely be entirely genetic.

Bipolar disorder is also considered a mood disorder and it is hypothesized that it might be caused by mitochondrial dysfunction.

Sex Differences

Mood disorders, specifically stress-related mood disorders such as anxiety and depression, have been shown to have differing rates of diagnosis based on sex. In the United States, women are two times more likely than men to be diagnosed with a stress-related mood disorder. Underlying these sex differences, studies have shown a dysregulation of stress-responsive neuroendocrine function causing an increase in the likelihood of developing these affective disorders. Overactivation of the hypothalamic-pituitary-adrenal (HPA) axis could provide potential insight into how these sex differences arise. Neuropeptide corticotropin-releasing factor (CRF) is released from the paraventricular nucleus (PVN) of the hypothalamus, stimulating adrenocorticotropic hormone (ACTH) release into the blood stream. From here ACTH triggers the release of glucocorticoids such as cortisol from the adrenal cortex. Cortisol, known as the main stress hormone, creates a negative feedback loop back to the hypothalamus to deactivate the stress response. When a constant stressor is present, the HPA axis remains overactivated and cortisol is constantly produced. This chronic stress is associated with sustained CRF release, resulting in the increased production of anxiety- and depressive-like behaviours and serving as a potential mechanism for differences in prevalence between men and women.

Diagnosis

DSM-5

The DSM-5, released in May 2013, separates the mood disorder chapter from the DSM-TR-IV into two sections: Depressive and related disorders and bipolar and related disorders. Bipolar disorders falls in between depressive disorders and schizophrenia spectrum and related disorders “in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology, family history and genetics” (Ref. 1, p 123). Bipolar disorders underwent a few changes in the DSM-5, most notably the addition of more specific symptomology related to hypomanic and mixed manic states. Depressive disorders underwent the most changes, the addition of three new disorders: disruptive mood dysregulation disorder, persistent depressive disorder (previously dysthymia), and premenstrual dysphoric disorder (previously in appendix B, the section for disorders needing further research). Disruptive mood dysregulation disorder is meant as a diagnosis for children and adolescents who would normally be diagnosed with bipolar disorder as a way to limit the bipolar diagnosis in this age cohort. Major depressive disorder (MDD) also underwent a notable change, in that the bereavement clause has been removed. Those previously exempt from a diagnosis of MDD due to bereavement are now candidates for the MDD diagnosis.

Treatment

There are different types of treatments available for mood disorders, such as therapy and medications. Behaviour therapy, cognitive behaviour therapy and interpersonal therapy have all shown to be potentially beneficial in depression. Major depressive disorder medications usually include antidepressants; a combination of antidepressants and cognitive behavioural therapy has shown to be more effective than one treatment alone. Bipolar disorder medications can consist of antipsychotics, mood stabilisers, anticonvulsants and/or lithium. Lithium specifically has been proven to reduce suicide and all causes of mortality in people with mood disorders. If mitochondrial dysfunction or mitochondrial diseases are the cause of mood disorders like bipolar disorder, then it has been hypothesized that N-acetyl-cysteine (NAC), acetyl-L-carnitine (ALCAR), S-adenosylmethionine (SAMe), coenzyme Q10 (CoQ10), alpha-lipoic acid (ALA), creatine monohydrate (CM), and melatonin could be potential treatment options. In determining treatment, there are many types of depression scales that are used.

  • One of the depression scales is a self-report scale called Beck Depression Inventory (BDI).
  • Another scale is the Hamilton Depression Rating Scale (HAMD).
    • HAMD is a clinical rating scale in which the patient is rated based on clinician observation.
  • The Centre for Epidemiologic Studies Depression Scale (CES-D) is a scale for depression symptoms that applies to the general population.
    • This scale is typically used in research and not for self-reports.
  • The PHQ-9 which stands for Patient-Health Questionnaire-9 questions, is a self-report as well.
  • Finally, the Mood Disorder Questionnaire (MDQ) evaluates bipolar disorder.

Research

Kay Redfield Jamison and others have explored the possible links between mood disorders – especially bipolar disorder – and creativity. It has been proposed that a “ruminating personality type may contribute to both [mood disorders] and art.”

Jane Collingwood notes an Oregon State University study that:

“…looked at the occupational status of a large group of typical patients and found that ‘those with bipolar illness appear to be disproportionately concentrated in the most creative occupational category.’ They also found that the likelihood of ‘engaging in creative activities on the job’ is significantly higher for bipolar than nonbipolar workers”.

In Liz Paterek’s article “Bipolar Disorder and the Creative Mind” she wrote:

“Memory and creativity are related to mania. Clinical studies have shown that those in a manic state will rhyme, find synonyms, and use alliteration more than controls. This mental fluidity could contribute to an increase in creativity. Moreover, mania creates increases in productivity and energy. Those in a manic state are more emotionally sensitive and show less inhibition about attitudes, which could create greater expression. Studies performed at Harvard looked into the amount of original thinking in solving creative tasks. Bipolar individuals, whose disorder was not severe, tended to show greater degrees of creativity.”

The relationship between depression and creativity appears to be especially strong among poets.

What are the Differential Diagnoses of Depression?

Introduction

Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. For example, depression in the United States (US) alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the US. In approximately 75% of completed suicides, the individuals had seen a physician within the prior year before their death, 45-66% within the prior month. About a third of those who completed suicide had contact with mental health services in the prior year, a fifth within the preceding month.

There are many psychiatric and medical conditions that may mimic some or all of the symptoms of depression or may occur comorbid to it. A disorder either psychiatric or medical that shares symptoms and characteristics of another disorder, and may be the true cause of the presenting symptoms is known as a differential diagnosis.

Many psychiatric disorders such as depression are diagnosed by allied health professionals with little or no medical training, and are made on the basis of presenting symptoms without proper consideration of the underlying cause, adequate screening of differential diagnoses is often not conducted. According to one study, non-medical mental health care providers may be at increased risk of not recognising masked medical illnesses in their patients.

Misdiagnosis or missed diagnoses may lead to lack of treatment or ineffective and potentially harmful treatment which may worsen the underlying causative disorder. A conservative estimate is that 10% of all psychological symptoms may be due to medical reasons, with the results of one study suggesting that about half of individuals with a serious mental illness have general medical conditions that are largely undiagnosed and untreated and may cause or exacerbate psychiatric symptoms.

In a case of misdiagnosed depression recounted in Newsweek, a writer received treatment for depression for years; during the last 10 years of her depression the symptoms worsened, resulting in multiple suicide attempts and psychiatric hospitalisations. When an MRI finally was performed, it showed the presence of a tumour. However, she was told by a neurologist that it was benign. After a worsening of symptoms, and upon the second opinion of another neurologist, the tumour was removed. After the surgery, she no longer suffered from depressive symptoms.

Autoimmune Disorders

  • Celiac disease:
    • This is an autoimmune disorder in which the body is unable to digest gluten which is found in various food grains, most notably wheat, and also rye and barley.
    • Current research has shown its neuropsychiatric symptoms may manifest without the gastrointestinal symptoms.
    • However, more recent studies have emphasized that a wider spectrum of neurologic syndromes may be the presenting extraintestinal manifestation of gluten sensitivity with or without intestinal pathology.
  • Lupus:
    • Systemic lupus erythematosus (SLE), is a chronic autoimmune connective tissue disease that can affect any part of the body.
    • Lupus can cause or worsen depression.

Bacterial-Viral-Parasitic Infection

  • Lyme disease:
    • This is a bacterial infection caused by Borrelia burgdorferi, a spirochete bacterium transmitted by the Deer tick (Ixodes scapularis).
    • Lyme disease is one of a group of diseases which have earned the name the “great imitator” for their propensity to mimic the symptoms of a wide variety of medical and neuropsychiatric disorders.
    • Lyme disease is an underdiagnosed illness, partially as a result of the complexity and unreliability of serologic testing.
    • Because of the rapid rise of Lyme borreliosis nationwide and the need for antibiotic treatment to prevent severe neurologic damage, mental health professionals need to be aware of its possible psychiatric presentations.
  • Syphilis:
    • The prevalence of which is on the rise, is another of the “great imitators”, which if left untreated can progress to neurosyphilis and affect the brain, can present with solely neuropsychiatric symptoms.
    • This case emphasises that neurosyphilis still has to be considered in the differential diagnosis within the context of psychiatric conditions and diseases.
    • Owing to current epidemiological data and difficulties in diagnosing syphilis, routine screening tests in the psychiatric field are necessary.
  • Neurocysticercosis (NCC):
    • This is an infection of the brain or spinal cord caused by the larval stage of the pork tapeworm, Taenia solium.
    • NCC is the most common helminthic (parasitic worm) infestation of the central nervous system worldwide. Humans develop cysticercosis when they ingest eggs of the pork tapeworm via contact with contaminated fecal matter or eating infected vegetables or undercooked pork.
    • While cysticercosis is endemic in Latin America, it is an emerging disease with increased prevalence in the United States.
    • The rate of depression in those with neurocysticercosis is higher than in the general population.
  • Toxoplasmosis:
    • This is an infection caused by Toxoplasma gondii an intracellular protozoan parasite. Humans can be infected in 3 different ways:
      • Ingestion of tissue cysts;
      • Ingestion of oocysts; or
      • In utero infection with tachyzoites.
    • One of the prime methods for transmission to humans is contact with the faeces of the host species, the domesticated cat.
    • Toxoplasma gondii infects approximately 30% of the world’s human population, but causes overt clinical symptoms in only a small segment of those infected.
    • Exposure to Toxoplasma gondii (seropositivity) without developing Toxoplasmosis has been proven to alter various characteristics of human behaviour as well as being a causative factor in some cases of depression, in addition, studies have linked seropositivity with an increased rate of suicide
  • West Nile virus (WNV):
    • This can cause encephalitis has been reported to be a causal factor in developing depression in 31% of those infected in a study conducted in Houston, Texas and reported to the Centre for Disease Control (CDC).
    • The primary vectors for disease transmission to humans are various species of mosquito.
    • WNV which is endemic to Southern Europe, Africa the Middle East and Asia was first identified in the United States in 1999.
    • Between 1999 and 2006, 20,000 cases of confirmed symptomatic WNV were reported in the US, with estimates of up to 1 million being infected.
    • WNV is now the most common cause of epidemic viral encephalitis in the United States, and it will likely remain an important cause of neurological disease for the foreseeable future.

Blood Disorders

  • Anaemia:
    • This is a decrease in normal number of red blood cells (RBCs) or less than the normal quantity of haemoglobin in the blood.
    • Depressive symptoms are associated with anaemia in a general population of older persons living in the community.

Chronic Fatigue Syndrome

Between 1 and 4 million Americans are believed to have chronic fatigue syndrome (CFS), yet only 50% have consulted a physician for symptoms of CFS. In addition individuals with CFS symptoms often have an undiagnosed medical or psychiatric disorder such as diabetes, thyroid disease or substance abuse. CFS, at one time considered to be psychosomatic in nature, is now considered to be a valid medical condition in which early diagnosis and treatment can aid in alleviating or completely resolving symptoms. While frequently misdiagnosed as depression, differences have been noted in rate of cerebral blood flow.

CFS is underdiagnosed in more than 80% of the people who have it; at the same time, it is often misdiagnosed as depression.

Dietary Disorders

  • Fructose malabsorption and lactose intolerance; deficient fructose transport by the duodenum, or by the deficiency of the enzyme, lactase in the mucosal lining, respectively.
  • As a result of this malabsorption the saccharides reach the colon and are digested by bacteria which convert them to short chain fatty acids, CO2, and H2.
  • Approximately 50% of those afflicted exhibit the physical signs of irritable bowel syndrome.
  • Fructose malabsorption may play a role in the development of depressed mood. Fructose malabsorption should be considered in patients with symptoms of major depression.
  • Fructose and sorbitol reduced diet in subjects with fructose malabsorption does not only reduce gastrointestinal symptoms but also improves mood and early signs of depression.

Endocrine System Disorders

Dysregulation of the endocrine system may present with various neuropsychiatric symptoms; irregularities in the hypothalamic-pituitary- adrenal (HPA) axis and the hypothalamic-pituitary-thyroid (HPT) axis have been shown in patients with primary depression.

HPT and HPA axes abnormalities observed in patients with depression:

  • HPT axes irregularities:
    • Alterations in thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH).
    • An abnormally high rate of antithyroid antibodies.
    • Elevated cerebrospinal fluid (CSF) TRH concentrations.
  • HPA axes irregularities:
    • Adrenocorticoid hypersecretion.
    • Enlarged pituitary and adrenal gland size (organomegaly).
    • Elevated corticotropin-releasing factor (CSF) concentrations.

Adrenal Gland

  • Addison’s disease:
    • Also known as chronic adrenal insufficiency, hypocortisolism, and hypocorticism) is a rare endocrine disorder wherein the adrenal glands, located above the kidneys, produce insufficient steroid hormones (glucocorticoids and often mineralocorticoids).
    • Addison’s disease presenting with psychiatric features in the early stage has the tendency to be overlooked and misdiagnosed.
  • Cushing’s Syndrome:
    • Also known as hypercortisolism, is an endocrine disorder characterised by an excess of cortisol.
    • In the absence of prescribed steroid medications, it is caused by a tumour on the pituitary or adrenal glands, or more rarely, an ectopic hormone-secreting tumour.
    • Depression is a common feature in diagnosed patients and it often improves with treatment.

Thyroid and Parathyroid Glands

  • Graves’ disease:
    • An autoimmune disease where the thyroid is overactive, resulting in hyperthyroidism and thyrotoxicosis.
  • Hashimoto’s thyroiditis:
    • Also known chronic lymphocytic thyroiditis is an autoimmune disease in which the thyroid gland is gradually destroyed by a variety of cell and antibody mediated immune processes.
    • Hashimoto’s thyroiditis is associated with thyroid peroxidase and thyroglobulin autoantibodies
  • Hashitoxicosis.
  • Hypothyroidism.
  • Hyperthyroidism.
  • Hypoparathyroidism:
    • Can affect calcium homeostasis, supplementation of which has completely resolved cases of depression in which hypoparathyroidism is the sole causative factor.

Pituitary Tumours

Tumours of the pituitary gland are fairly common in the general population with estimates ranging as high as 25%. Most tumours are considered to be benign and are often an incidental finding discovered during autopsy or as of neuroimaging in which case they are dubbed “incidentalomas”. Even in benign cases, pituitary tumours can affect cognitive, behavioural and emotional changes. Pituitary microadenomas are smaller than 10 mm in diameter and are generally considered benign, yet the presence of a microadenoma has been positively identified as a risk factor for suicide.

Patients with pituitary disease are diagnosed and treated for depression and show little response to the treatment for depression.

Pancreas

  • Hypoglycemia:
    • An overproduction of insulin causes reduced blood levels of glucose.
    • In one study of patients recovering from acute lung injury in intensive care, those patients who developed hypoglycaemia while hospitalised showed an increased rate of depression.

Neurological

Central Nervous System Tumours

In addition to pituitary tumours, tumours in various locations in the central nervous system (CNS) may cause depressive symptoms and be misdiagnosed as depression.

Post Concussion Syndrome

Post-concussion syndrome (PCS), is a set of symptoms that a person may experience for weeks, months, or occasionally years after a concussion with a prevalence rate of 38-80% in mild traumatic brain injuries, it may also occur in moderate and severe cases of traumatic brain injury. A diagnosis may be made when symptoms resulting from concussion, depending on criteria, last for more than three to six months after the injury, in which case it is termed persistent post-concussive syndrome (PPCS). In a study of the prevalence of post concussion syndrome symptoms in patients with depression utilising the British Columbia Post-concussion Symptom Inventory: “Approximately 9 out of 10 patients with depression met liberal self-report criteria for a post-concussion syndrome and more than 5 out of 10 met conservative criteria for the diagnosis.” These self reported rates were significantly higher than those obtained in a scheduled clinical interview. Normal controls have exhibited symptoms of PCS as well as those seeking psychological services. There is considerable debate over the diagnosis of PCS in part because of the medico-legal and thus monetary ramifications of receiving the diagnosis.

Pseudobulbar Affect

Pseudobulbar affect (PBA) is an affective disinhibition syndrome that is largely unrecognised in clinical settings and thus often untreated due to ignorance of the clinical manifestations of the disorder; it may be misdiagnosed as depression. It often occurs secondary to various neurodegenerative diseases such as amyotrophic lateral sclerosis, and also can result from head trauma. PBA is characterised by involuntary and inappropriate outbursts of laughter and/or crying. PBA has a high prevalence rate with estimates of 1.5-2 million cases in the United States alone.

Multiple Sclerosis

Multiple sclerosis is a chronic demyelinating disease in which the myelin sheaths of cells in the brain and spinal cord are irreparably damaged. Symptoms of depression are very common in patients at all stages of the disease and may be exacerbated by medical treatments, notably interferon beta-1a.

Neurotoxicity

Various compounds have been shown to have neurotoxic effects many of which have been implicated as having a causal relationship in the development of depression.

Cigarette Smoking

There has been research which suggests a correlation between cigarette smoking and depression. The results of one recent study suggest that smoking cigarettes may have a direct causal effect on the development of depression. There have been various studies done showing a positive link between smoking, suicidal ideation and suicide attempts.

In a study conducted among nurses, those smoking between 1-24 cigarettes per day had twice the suicide risk; 25 cigarettes or more, 4 times the suicide risk, than those who had never smoked. In a study of 300,000 male US Army soldiers, a definitive link between suicide and smoking was observed with those smoking over a pack a day having twice the suicide rate of non-smokers.

Medication

Various medications have been suspected of having a causal relation in the development of depression; this has been classified as “organic mood syndrome”. Some classes of medication such as those used to treat hypertension, have been recognised for decades as having a definitive relationship with the development of depression.

Monitoring of those taking medications which have shown a relationship with depression is often indicated, as well as the necessity of factoring in the use of such medications in the diagnostic process.

  • Topical Tretinoin (Retin-A):
    • Derived from Vitamin A and used for various medical conditions such as in topical solutions used to treat acne vulgaris.
    • Although applied externally to the skin, it may enter the bloodstream and cross the blood brain barrier where it may have neurotoxic effects.
  • Interferons:
    • Proteins produced by the human body, three types have been identified alpha, beta and gamma.
    • Synthetic versions are utilised in various medications used to treat different medical conditions such as the use of interferon-alpha in cancer treatment and hepatitis C treatment.
    • All three classes of interferons may cause depression and suicidal ideation.

Chronic Exposure to Organophosphates

The neuropsychiatric effects of chronic organophosphate exposure include mood disorders, suicidal thinking and behaviour, cognitive impairment and chronic fatigue.

Neuropsychiatric

Bipolar Disorder

Bipolar disorder is frequently misdiagnosed as major depression, and is thus treated with antidepressants alone which is not only not efficacious it is often contraindicated as it may exacerbate hypomania, mania, or cycling between moods. There is ongoing debate about whether this should be classified as a separate disorder because individuals diagnosed with major depression often experience some hypomanic symptoms, indicating a continuum between the two.

Nutritional Deficiencies

Nutrition plays a key role in every facet of maintaining proper physical and psychological wellbeing. Insufficient or inadequate nutrition can have a profound effect on mental health. The emerging field of nutritional neuroscience explores the various connections between diet, neurological functioning and mental health.

  • Vitamin B6:
    • Pyridoxal phosphate (PLP), the active form of B6, is a cofactor in the dopamine serotonin pathway, a deficiency in vitamin B6 may cause depressive symptoms.
  • Folate (vitamin B9) – Vitamin B12 cobalamin:
    • Low blood plasma and particularly red cell folate and diminished levels of vitamin B12 have been found in patients with depressive disorders.
    • Research suggests that oral doses of both folic acid (800 μg/(mcg) daily) and vitamin B12 (1 mg daily) should be tried to improve treatment outcome in depression.
  • Long chain fatty acids:
    • Higher levels of omega-6 and lower levels of omega-3 fatty acids has been associated with depression and behavioural change.
  • Vitamin D deficiency is associated with depression

Sleep Disorders

  • Insomnia:
    • While the inability to fall asleep is often a symptom of depression, it can also in some instances serve as the trigger for developing a depressive disorder.
    • It can be transient, acute or chronic.
    • It can be a primary disorder or a co-morbid one.
  • Restless legs syndrome (RLS):
    • Also known as Wittmaack-Ekbom’s syndrome, is characterised by an irresistible urge to move one’s body to stop uncomfortable or odd sensations.
    • It most commonly affects the legs, but can also affect the arms or torso, and even phantom limbs.
    • Restless Leg syndrome has been associated with Major depressive disorder.
    • Adjusted odds ratio for diagnosis of major depressive disorder suggest a strong association between restless legs syndrome and major depressive disorder and/or panic disorder.
  • Sleep apnea:
    • This is a sleep disorder characterised by pauses in breathing during sleep.
    • Each episode, called an apnoea, lasts long enough for one or more breaths to be missed; such episodes occur repeatedly throughout the sleep cycle.
    • Undiagnosed sleep apnoea may cause or contribute to the severity of depression.
  • Circadian rhythm sleep disorders:
    • Few clinicians are aware, and often goes untreated or are treated inappropriately, as when misdiagnosed as either primary insomnia or as a psychiatric condition.

What is Depression (Mood)?

Introduction

Depression is a state of low mood and aversion to activity. It can affect a person’s thoughts, behaviour, motivation, feelings, and sense of well-being.

The core symptom of depression is said to be anhedonia, which refers to loss of interest or a loss of feeling of pleasure in certain activities that usually bring joy to people. Depressed mood is a symptom of some mood disorders such as major depressive disorder or dysthymia; it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments.

It may feature sadness, difficulty in thinking and concentration and a significant increase or decrease in appetite and time spent sleeping. People experiencing depression may have feelings of dejection, hopelessness and, sometimes, suicidal thoughts. It can either be short term or long term.

Epidemiology

Depression is the leading cause of disability worldwide, the United Nations (UN) health agency reported, estimating that it affects more than 300 million people worldwide – the majority of them women, young people and the elderly. An estimated 4.4% of the global population suffers from depression, according to a report released by the UN World Health Organisation (WHO), which shows an 18 percent increase in the number of people living with depression between 2005 and 2015.

Global Health

Depression is a major mental-health cause of disease burden. Its consequences further lead to significant burden in public health, including a higher risk of dementia, premature mortality arising from physical disorders, and maternal depression impacts on child growth and development. Approximately 76% to 85% of depressed people in low- and middle-income countries do not receive treatment;[48] barriers to treatment include: inaccurate assessment, lack of trained health-care providers, social stigma and lack of resources.

The WHO has constructed guidelines – known as The Mental Health Gap Action Programme (mhGAP) – aiming to increase services for people with mental, neurological and substance-use disorders. Depression is listed as one of conditions prioritised by the programme. Trials conducted show possibilities for the implementation of the programme in low-resource primary-care settings dependent on primary-care practitioners and lay health-workers. Examples of mhGAP-endorsed therapies targeting depression include Group Interpersonal Therapy as group treatment for depression and “Thinking Health”, which utilises cognitive behavioural therapy to tackle perinatal depression. Furthermore, effective screening in primary care is crucial for the access of treatments. The mhGAP programme adopted its approach of improving detection rates of depression by training general practitioners. However, there is still weak evidence supporting this training.

History of the Concept

The Greco-Roman world used the tradition of the four humours to attempt to systematise sadness as “melancholia”.

The well-established idea of melancholy fell out of scientific favour in the 19th century.

Emil Kraepelin tried to give a scientific account of depression (German: das manisch-depressive Irresein) in 1896.

Factors

Life Events

Adversity in childhood, such as bereavement, neglect, mental abuse, physical abuse, sexual abuse, or unequal parental treatment of siblings can contribute to depression in adulthood. Childhood physical or sexual abuse in particular significantly correlates with the likelihood of experiencing depression over the victim’s lifetime.

Life events and changes that may influence depressed moods include (but are not limited to): childbirth, menopause, financial difficulties, unemployment, stress (such as from work, education, family, living conditions etc.), a medical diagnosis (cancer, HIV, etc.), bullying, loss of a loved one, natural disasters, social isolation, rape, relationship troubles, jealousy, separation, or catastrophic injury. Adolescents may be especially prone to experiencing a depressed mood following social rejection, peer pressure, or bullying.

Personality

Changes in personality or in one’s social environment can affect levels of depression. High scores on the personality domain neuroticism make the development of depressive symptoms as well as all kinds of depression diagnoses more likely, and depression is associated with low extraversion. Other personality indicators could be: temporary but rapid mood changes, short term hopelessness, loss of interest in activities that used to be of a part of one’s life, sleep disruption, withdrawal from previous social life, appetite changes, and difficulty concentrating.

Medical Treatment

Depression may also be the result of healthcare, such as with medication induced depression. Therapies associated with depression include interferon therapy, beta-blockers, isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics, and hormonal agents such as gonadotropin-releasing hormone agonist.

Substance-Induced

Several drugs of abuse can cause or exacerbate depression, whether in intoxication, withdrawal, and from chronic use. These include alcohol, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs such as heroin), stimulants (such as cocaine and amphetamines), hallucinogens, and inhalants.

Non-Psychiatric Illnesses

Refer to Differential Diagnoses of Depression.

Depressed mood can be the result of a number of infectious diseases, nutritional deficiencies, neurological conditions, and physiological problems, including hypoandrogenism (in men), Addison’s disease, Cushing’s syndrome, hypothyroidism, hyperparathyroidism, Lyme disease, multiple sclerosis, Parkinson’s disease, chronic pain, stroke, diabetes, and cancer.

Psychiatric Syndromes

Refer to Depressive Mood Disorders.

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode.

Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition, and energy levels, but may also involve one or more episodes of depression. When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder.

Outside the mood disorders: borderline personality disorder often features an extremely intense depressive mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioural symptoms are significant but do not meet the criteria for a major depressive episode; and posttraumatic stress disorder, a mental disorder that sometimes follows trauma, is commonly accompanied by depressed mood.

Historical Legacy

Refer to Dispossession, Oppression and Depression.

Researchers have begun to conceptualise ways in which the historical legacies of racism and colonialism may create depressive conditions.

Measures of Depression

Measures of depression as an emotional disorder include (but are not limited to) the Beck Depression Inventory-11 and the 9-item depression scale in the Patient Health Questionnaire.

Both of these measures are psychological tests that ask personal questions of the participant, and have mostly been used to measure the severity of depression. The Beck Depression Inventory (BDI) is a self-report scale that helps a therapist identify the patterns of depression symptoms and monitor recovery. The responses on this scale can be discussed in therapy to devise interventions for the most distressing symptoms of depression. Several studies, however, have used these measures to also determine healthy individuals who are not suffering from depression as a mental disorder, but as an occasional mood disorder. This is substantiated by the fact that depression as an emotional disorder displays similar symptoms to minimal depression and low levels of mental disorders such as major depressive disorder; therefore, researchers were able to use the same measure interchangeably. In terms of the scale, participants scoring between 0-13 and 0-4 respectively were considered healthy individuals.

Another measure of depressed mood would be the IWP Multi-affect Indicator. It is a psychological test that indicates various emotions, such as enthusiasm and depression, and asks for the degree of the emotions that the participants have felt in the past week. There are studies that have used lesser items from the IWP Multi-affect Indicator which was then scaled down to daily levels to measure the daily levels of depression as an emotional disorder.

Connections

Alcoholism

Alcohol can be a depressant which slows down some regions of the brain, like the prefrontal and temporal cortex, negatively affecting rationality and memory. It also lowers the level of serotonin in the brain, which could potentially lead to higher chances of depressive mood.

The connection between the amount of alcohol intake, level of depressed mood, and how it affects the risks of experiencing consequences from alcoholism, were studied in a research done on college students. The study used 4 latent, distinct profiles of different alcohol intake and level of depression; Mild or Moderate Depression, and Heavy or Severe Drinkers. Other indicators consisting of social factors and individual behaviours were also taken into consideration in the research. Results showed that the level of depression as an emotion negatively affected the amount of risky behaviour and consequence from drinking, while having an inverse relationship with protective behavioural strategies, which are behavioural actions taken by oneself for protection from the relative harm of alcohol intake. Having an elevated level of depressed mood does therefore lead to greater consequences from drinking.

Bullying

Social abuse, such as bullying, are defined as actions of singling out and causing harm on vulnerable individuals. In order to capture a day-to-day observation of the relationship between the damaging effects of social abuse, the victim’s mental health and depressive mood, a study was conducted on whether individuals would have a higher level of depressed mood when exposed to daily acts of negative behaviour. The result concluded that being exposed daily to abusive behaviours such as bullying has a positive relationship to depressed mood on the same day.

The study has also gone beyond to compare the level of depressive mood between the victims and non-victims of the daily bullying. Although victims were predicted to have a higher level of depressive mood, the results have shown otherwise that exposure to negative acts has led to similar levels of depressive mood, regardless of the victim status. The results therefore have concluded that bystanders and non-victims feel as equally depressed as the victim when being exposed to acts such as social abuse.

Creative Thinking

Divergent thinking is defined as a thought process that generates creativity in ideas by exploring many possible solutions. Having a depressed mood will significantly reduce the possibility of divergent thinking, as it reduces the fluency, variety and the extent of originality of the possible ideas generated.

However, some depressive mood disorders might have a positive effect for creativity. Upon identifying several studies and analysing data involving individuals with high levels of creativity, Christa Taylor was able to conclude that there is a clear positive relationship between creativity and depressive mood. A possible reason is that having a low mood could lead to new ways of perceiving and learning from the world, but it is unable to account for certain depressive disorders. The direct relationship between creativity and depression remains unclear, but the research conducted on this correlation has shed light that individuals who are struggling with a depressive disorder may be having even higher levels of creativity than a control group, and would be a close topic to monitor depending on the future trends of how creativity will be perceived and demanded.

Stress Management Techniques

There are empirical evidences of a connection between the type of stress management techniques and the level of daily depressive mood.

Problem-focused coping leads to lower level of depression. Focusing on the problem allows for the subjects to view the situation in an objective way, evaluating the severity of the threat in an unbiased way, thus it lowers the probability of having depressive responses. On the other hand, emotion-focused coping promotes a depressed mood in stressful situations. The person has been contaminated with too much irrelevant information and loses focus on the options for resolving the problem. They fail to consider the potential consequences and choose the option that minimises stress and maximises well-being.

Management

Depressed mood may not require professional treatment, and may be a normal temporary reaction to life events, a symptom of some medical condition, or a side effect of some drugs or medical treatments. A prolonged depressed mood, especially in combination with other symptoms, may lead to a diagnosis of a psychiatric or medical condition which may benefit from treatment. The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicated that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. Physical activity can have a protective effect against the emergence of depression.

Physical activity can also decrease depressive symptoms due to the release of neurotrophic proteins in the brain that can help to rebuild the hippocampus that may be reduced due to depression. Also yoga could be considered an ancillary treatment option for patients with depressive disorders and individuals with elevated levels of depression.

Reminiscence of old and fond memories is another alternative form of treatment, especially for the elderly who have lived longer and have more experiences in life. It is a method that causes a person to recollect memories of their own life, leading to a process of self-recognition and identifying familiar stimuli. By maintaining one’s personal past and identity, it is a technique that stimulates people to view their lives in a more objective and balanced way, causing them to pay attention to positive information in their life stories, which would successfully reduce depressive mood levels.

Self-help books are a growing form of treatment for peoples physiological distress. There may be a possible connection between consumers of unguided self-help books and higher levels of stress and depressive symptoms. Researchers took many factors into consideration to find a difference in consumers and non-consumers of self-help books. The study recruited 32 people between the ages of 18 and 65; 18 consumers and 14 non-consumers, in both groups 75% of them were female. Then they broke the consumers into 11 who preferred problem-focused and 7 preferred growth-oriented. Those groups were tested for many things including cortisol levels, depressive symptomatology, and stress reactivity levels. There were no large differences between consumers of self-help books and non-consumers when it comes to diurnal cortisol level, there was a large difference in depressive symptomatology with consumers having a higher mean score. The growth-oriented group has higher stress reactivity levels than the problem-focused group. However, the problem-focused group shows higher depressive symptomatology.

Book: Anxiety and Depression in Children and Adolescents

Book Title:

Anxiety and Depression in Children and Adolescents: Assessment, Intervention, and Prevention.

Author(s): Thomas J. Huberty..

Year: 2012.

Edition: First (1st).

Publisher: Springer.

Type(s): Hardcover and eBook.

Synopsis:

Although generally considered adult disorders, anxiety and depression are widespread among children and adolescents, affecting academic performance, social development, and long-term outcomes. They are also difficult to treat and, especially when they occur in tandem, tend to fly under the diagnostic radar.

Anxiety and Depression in Children and Adolescents offers a developmental psychology perspective for understanding and treating these complex disorders as they manifest in young people. Adding the school environment to well-known developmental contexts such as biology, genetics, social structures, and family, this significant volume provides a rich foundation for study and practice by analyzing the progression of pathology and the critical role of emotion regulation in anxiety disorders, depressive disorders, and in combination. Accurate diagnostic techniques, appropriate intervention methods, and empirically sound prevention strategies are given accessible, clinically relevant coverage. Illustrative case examples and an appendix of forms and checklists help make the book especially useful.

Featured in the text:

  • Developmental psychopathology of anxiety, anxiety disorders, depression, and mood disorders.
  • Differential diagnosis of the anxiety and depressive disorders.
  • Assessment measures for specific conditions.
  • Age-appropriate interventions for anxiety and depression, including CBT and pharmacotherapy.
  • Multitier school-based intervention and community programmes.
  • Building resilience through prevention.

Anxiety and Depression in Children and Adolescents is an essential reference for practitioners, researchers, and graduate students in school and clinical child psychology, mental health and school counselling, family therapy, psychiatry, social work, and education.

Book: Mental Health Emergencies

Book Title:

Mental Health Emergencies: A Guide to Recognising and Handling Mental Health Crises.

Author(s): Nick Benas and Michele Hart (LCSW).

Year: 2017.

Edition: First (1st).

Publisher: Hatherleigh Press.

Type(s): Paperback and Kindle.

Synopsis:

One in three people will deal with some kind of mental health concern during their lifetime and odds of knowing a loved one dealing with problems in mental health is even greater.

Mental Health First Aid is a comprehensive guide that provides an overview of the most common mental health problems as well as provide expert guidance on more serious problems such as self-injury, eating disorders, substance abuse, psychosis and attempted suicides.

Book: Way from Chaos to a Better Life

Book Title:

Way from Chaos to a Better Life: Developing Mental health and Recovering from a Mental Illness: By a Survivor’s Inside-Out Persepctive.

Author(s): Henri Kulm.

Year: 2020.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.

Synopsis:

My name is Henri. I was born in 1990 in the capital of Estonia, Tallinn and I have lived there my entire life. I have been diagnosed with schizoaffective disorder, mixed type. This means that I must cope with psychotic episodes and mood disturbances (symptoms of schizophrenia and bipolar disorder). I have been struck by the illness more seriously twice: the first blow was, when I was 22 years old, and the second one was, when I was 25 years old. I have gotten my education by finishing a bachelors and master's degree in energetics and now, I work full-timely in that area. I have gotten my training from Tallinn Mental Health Centre and Loov Ruum Koolitused OÜ to be a licensed experience counsellor and I have been involved in the following activities during my work at Tallinn Mental Health Centre: Individual and group counselling, sharing experience story, conducting trainings, representing organization in media. In the training process, I decided to write deeply about my experience recovering from a major mental illness and I want share that with you. Experience counsellor is a person, who has been diagnosed with a mental illness, but has recovered well. He/she can tell his/her experience with the illness from inside and share things, what a psychiatrist or a psychologist might not know. Because the speciality of the sufferers illness is different in every case, the experience counsellor does not give concrete advice, but encourages and supports basing on his/her experience. Despite the risk of possible negative attitudes from society, I wish to publish this book, because after my first psychotic episode and first treatment in the psychiatric hospital, I fell into the zero point of life. It took a lot of time and work to get out of that zero point and now, I can say that I am satisfied with my life. I have been able to live a full life, start and finish a master’s degree, work full timely in my area and be a licensed experience counsellor. I wish to help people with mental illnesses to recover from a mental illness, to re-establish life quality and develop mental health. I wish to show that recovery from a major mental illness is possible. This book might also be useful to people, who are mentally well, but wish to gain more insight of what a mental illness is all about. This book might also be useful to professionals of mental health.

Book: Mental Health Journal: Anxiety and Depression Journal

Book Title:

Mental Health Journal: Anxiety and Depression Journal. Mental Health Journal & Mood Tracker – Thoughts and Feelings Tracker – PTSD and Depression … Goals, Promote Positive Thinking & Gratitude.

Author(s): R. Roslinda.

Year: 2020.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback.

Synopsis:

This Mental Health Journal & Mood Tracker is designed to help you keep track of your mental and emotional wellbeing. Ideal for anyone struggling with anxiety and mood disorders: depression, ADHD, Bipolar etc. The journal features a 12 monthly daily mood tracker, pages for you to write down your feelings and thoughts. Keep notes on things you are grateful for and your achievements. There are also spaces for you to jot down stuff like, things you did well at today, things that made you smile, things that you had fun doing and enjoyed, things you did that made you feel proud. You can also make notes on goals you want to accomplish.

Features:

  • Mood Tracker For 12 Months: Angry, Ashamed, Confused, Excited….
  • Anxiety Levels Chart-Mood Chart-Section with writing prompts: How do I feel?, Today I am grateful for…, Something I did well today, I felt proud when…
  • and many more!

Major Depressive Disorder: Childhood Trauma

Research Paper Title

Major depressive disorder with childhood trauma: Clinical characteristics, biological mechanism, and therapeutic implications.

Background

Major depressive disorder (MDD) is a main type of mood disorder, characterised by significant and lasting depressed mood.

Until now, the pathogenesis of MDD is not clear, but it is certain that biological, psychological, and social factors are involved.

Childhood trauma is considered to be an important factor in the development of this disease.

Previous studies have found that nearly half of the patients with MDD have experienced childhood trauma, and different types of childhood trauma, gender, and age show different effects on this disease.

In addition, the clinical characteristics of MDD patients with childhood trauma are also different, which often have more severe depressive symptoms, higher risk of suicide, and more severe cognitive impairment.

The response to antidepressants is also worse.

In terms of biological mechanisms and marker characteristics, the serotonin transporter gene and the FKBP prolyl isomerase 5 have been shown to play an important role in MDD and childhood trauma.

Moreover, some brain imaging and biomarkers showed specific features, such as changes in gray matter in the dorsal lateral prefrontal cortex, and abnormal changes in hypothalamic-pituitary-adrenal axis function.

Reference

Guo, W., Liu, J. & Li, L. (2020) Major depressive disorder with childhood trauma:Clinical characteristics, biological mechanism, and therapeutic implications. Zhong nan da xue xue bao. Journal of Central South University. 45(4), pp.462-468. doi: 10.11817/j.issn.1672-7347.2020.190699.