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A Brief Lecture on Depressive Related and Bipolar Disorder

by CDC, DSM-5, NIMH, NIH and SAMHSA

 

Introduction to Abnormal Psychology and Life

Perspectives on Abnormal Psycholog

Risk and Prevention of Psychological Disorders

Diagnosis and Assessment of Psychological Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Somatic Symptom and Dissociative Disorders

Depressive and Bipolar Disorders

Eating Disorders

Substance-Related Disorders

Personality Disorders

Sexual Dysfunctions

Schizophrenia and Other Psychotic Disorders

Developmental and Disruptive Behavior Disorders

 
 
 

Depressive Disorders and Bipolar Disorders

According to the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5, 2013), “the common feature of all depressive disorders is the presence of sadness, empathy, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.”

In the newly published Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5, 2013), bipolar and related disorders are discussed in a category by themselves. This is in contrast to DSM-IV-R, where they were a part of mood disorders.

On this page, we will discuss various depressive and bipolar disorders.

 
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Information on Depression from Center for Disease Control and Prevention

  • During 2009–2012, 7.6% of Americans aged 12 and over had depression.
  • About 3% of Americans aged 12 and over had severe depressive symptoms, while almost 78% had no symptoms.
  • Persons living below the poverty level were nearly 2½ times more likely to have depression than those at or above the poverty level.
  • Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home, and social activities. Of those with severe symptoms, 35% reported having contact with a mental health professional in the past year.
  • Women have depression more often than men. Biological, lifecycle, and hormonal factors that are unique to women may be linked to their higher depression rate. Women with depression typically have symptoms of sadness, worthlessness, and guilt.
  • Men with depression are more likely to be very tired, irritable, and sometimes angry. They may lose interest in work or activities they once enjoyed, have sleep problems, and behave recklessly, including the misuse of drugs or alcohol. Many men do not recognize their depression and fail to seek help.
  • Older adults with depression may have less obvious symptoms, or they may be less likely to admit to feelings of sadness or grief. They are also more likely to have medical conditions, such as heart disease, which may cause or contribute to depression.
  • Younger children with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die.
  • Older children and teens with depression may get into trouble at school, sulk, and be irritable. Teens with depression may have symptoms of other disorders, such as anxiety, eating disorders, or substance abuse.
 
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Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts. DMDD symptoms go beyond a being a “moody” child—children with DMDD experience severe impairment that requires clinical attention.

As a newly added childhood disorder, disruptive mood dysregulation disorder is characterized by severe irritability, anger, and frequesny temper outbursts that can be presented verbally and/or behaviorally. The outbursts are exaggerated reactions and inappropriate in their frustration level, duration, and intensity. The frequency of the outbursts must be at least three or more times per week in three consecutive months during the 12-month period (DSM-5, 2013). According to DSM-5 (2013), diagnostic criteria for disruptive mood dysregulation disorder are:

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).

E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting three or more consecutive months without all of the symptoms in Criteria A-D.

F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.

G. The diagnosis should not be made for the first time before age six years or after age 18 years.

H. By history or observation, the age at onset of Criteria A-E is before 10 years.

I. There has never been a distinct period lasting more than one day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder (dysthymia).

Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Great Videos and Information on Disruptive Mood Dysregulation Disorder from NIMH
 
 
 

Definition

Disruptive mood dysregulation disorder (DMDD) is a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts. DMDD symptoms go beyond a being a “moody” child—children with DMDD experience severe impairment that requires clinical attention. DMDD is a fairly new diagnosis, appearing for the first time in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013.

Signs and Symptoms

DMDD symptoms typically begin before the age of 10, but the diagnosis is not given to children under 6 or adolescents over 18. A child with DMDD experiences:

  • Irritable or angry mood most of the day, nearly every day
  • Severe temper outbursts (verbal or behavioral) at an average of three or more times per week that are out of keeping with the situation and the child’s developmental level
  • Trouble functioning due to irritability in more than one place (e.g., home, school, with peers)

To be diagnosed with DMDD, a child must have these symptoms steadily for 12 or more months.

Risk Factors

It is not clear how widespread DMDD is in the general population, but it is common among children who visit pediatric mental health clinics. Researchers are exploring risk factors and brain mechanisms of this disorder.

Treatment and Therapies

DMDD is a new diagnosis. Therefore, treatment is often based on what has been helpful for other disorders that share the symptoms of irritability and temper tantrums  . These disorders include attention deficit hyperactivity disorder (ADHD), anxiety disorders, oppositional defiant disorder, and major depressive disorder.

If you think your child has DMDD, it is important to seek treatment. DMDD can impair a child’s quality of life and school performance and disrupt relationships with his or her family and peers. Children with DMDD may find it hard to participate in activities or make friends. Having DMDD also increases the risk of developing depression or anxiety disorders in adulthood.

While researchers are still determining which treatments work best, two major types of treatment are currently used to treat DMDD symptoms:

  • Medication
  • Psychological treatments
    • Psychotherapy
    • Parent training
    • Computer based training

Psychological treatments should be considered first, with medication added later if necessary, or psychological treatments can be provided along with medication from the beginning.

It is important for parents or caregivers to work closely with the doctor to make a treatment decision that is best for their child.

Biologically Based Treatment
Medication

Many medications used to treat children and adolescents with mental illness are effective in relieving symptoms. However, some of these medications have not been studied in depth and/or do not have U.S. Food and Drug Administration (FDA)  approval for use with children or adolescents. All medications have side effects and the need for continuing them should be reviewed frequently with your child’s doctor.

For basic information about these and other mental health medications, you can visit the NIMH Mental Health Medications webpage. For the most up-to-date information on medications, side effects, and warnings, visit the FDA website  .

Stimulants

Stimulants are medications that are commonly used to treat ADHD. There is evidence that, in children with irritability and ADHD, stimulant medications also decrease irritability.

Stimulants should not be used in individuals with serious heart problems. According to the FDA  , people on stimulant medications should be periodically monitored for change in heart rate and blood pressure.

Antidepressants

Antidepressant medication is sometimes used to treat the irritability and mood problems associated with DMDD. Ongoing studies are testing whether these medicines are effective for this problem. It is important to note that, although antidepressants are safe and effective for many people, they carry a risk of suicidal thoughts and behavior in children and teens. A “black box” warning—the most serious type of warning that a prescription can carry—has been added to the labels of these medications to alert parents and patients to this risk. For this reason, a child taking an antidepressant should be monitored closely, especially when they first start taking the medication.

Atypical Antipsychotic

An atypical antipsychotic medication may be prescribed for children with very severe temper outbursts that involve physical aggression toward people or property. Risperidone  and aripiprazole  are FDA-approved for the treatment of irritability associated with autism and are sometimes used to treat DMDD. Atypical antipsychotic medications are associated with many significant side-effects, including suicidal ideation/behaviors, weight gain, metabolic abnormalities, sedation, movement disorders, hormone changes, and others.

Psychological treatments
Psychotherapy

Cognitive-behavioral therapy, a type of psychotherapy, is commonly used to teach children and teens how to deal with thoughts and feelings that contribute to their feeling depressed or anxious. Clinicians can use similar techniques to teach children to more effectively regulate their mood and to increase their tolerance for frustration. The therapy also teaches coping skills for regulating anger and ways to identify and re-label the distorted perceptions that contribute to outbursts. Other research psychotherapies are being explored at the NIMH.

Parent Training

Parent training aims to help parents interact with a child in a way that will reduce aggression and irritable behavior and improve the parent-child relationship. Multiple studies show that such interventions can be effective. Specifically, parent training teaches parents more effective ways to respond to irritable behavior, such as anticipating events that might lead a child to have a temper outburst and working ahead to avert the outburst. Training also focuses on the importance of predictability, being consistent with children, and rewarding positive behavior.

Computer-based training

Evidence suggests that irritable youth with DMDD may be prone to misperceiving ambiguous facial expressions as angry. There is preliminary evidence that computer-based training designed to correct this problem may help youth with DMDD or severe irritability  .

Join a Study

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. During clinical trials, treatments might be new drugs or combinations of drugs, new psychotherapies or devices, or new ways to use existing treatments. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Please note: Decisions about whether to participate in a clinical trial and which ones are best suited for a given individual are best made in collaboration with your licensed health professional.
Clinical Trials at NIMH/NIH

Scientists at the NIMH campus conduct research on numerous areas of study, including cognition, genetics, epidemiology, and psychiatry. The studies take place at the NIH Clinical Center in Bethesda, Maryland and usually require regular visits. After an initial phone interview to see if any of the clinical trials recruiting subjects are a good match for you, you will come to an appointment at the clinic and meet with a clinician. Visit the NIMH Clinical Trials — Participants or Join a Study: Disruptive Mood Dysregulation Disorder for more information.

How Do I Find a Clinical Trial Near Me?

To find a clinical trial near you, you can visit ClinicalTrials.gov  . This is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov gives you information about a trial's purpose, who may participate, locations, and contact information for more details. This information should be used in conjunction with advice from your health provider.

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Major Depressive Disorder

Individuals diagnosed with major depressive disorder, for at least two weeks, indicate five or more of the following symptoms that suggest a modification from past functioning. According to DSM-5 (2013), the diagnostic criteria for major depressive disorder are:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

  • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

(Note: In children, consider failure to make expected weight gain.)

  • Insomnia or hypersomnia nearly every day.
  • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  • Fatigue or loss of energy nearly every day.
  • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Note: Do not include symptoms that are clearly attributable to another medical condition.

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

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note: Criteria A-C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

Great Videos and Information on Major Depressive Disorder from NIMH
   
 
   

Definition

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.

Some forms of depression are slightly different, or they may develop under unique circumstances, such as:

  • Persistent depressive disorder (also called dysthymia)is a depressed mood that lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years to be considered persistent depressive disorder.
  • Perinatal depression is much more serious than the “baby blues” (relatively mild depressive and anxiety symptoms that typically clear within two weeks after delivery) that many women experience after giving birth. Women with perinatal depression experience full-blown major depression during pregnancy or after delivery (postpartum depression). The feelings of extreme sadness, anxiety, and exhaustion that accompany perinatal depression may make it difficult for these new mothers to complete daily care activities for themselves and/or for their babies.
  • Psychotic depression occurs when a person has severe depression plus some form of psychosis, such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations). The psychotic symptoms typically have a depressive “theme,” such as delusions of guilt, poverty, or illness.
  • Seasonal affective disorder is characterized by the onset of depression during the winter months, when there is less natural sunlight. This depression generally lifts during spring and summer. Winter depression, typically accompanied by social withdrawal, increased sleep, and weight gain, predictably returns every year in seasonal affective disorder.
  • Bipolar disorder is different from depression, but it is included in this list is because someone with bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression (called “bipolar depression”). But a person with bipolar disorder also experiences extreme high – euphoric or irritable – moods called “mania” or a less severe form called “hypomania.”

Examples of other types of depressive disorders newly added to the diagnostic classification of DSM-5  include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder (PMDD).

Signs and Symptoms

If you have been experiencing some of the following signs and symptoms most of the day, nearly every day, for at least two weeks, you may be suffering from depression:

  • Persistent sad, anxious, or “empty” mood
  • Feelings of hopelessness, or pessimism
  • Irritability
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest or pleasure in hobbies and activities
  • Decreased energy or fatigue
  • Moving or talking more slowly
  • Feeling restless or having trouble sitting still
  • Difficulty concentrating, remembering, or making decisions
  • Difficulty sleeping, early-morning awakening, or oversleeping
  • Appetite and/or weight changes
  • Thoughts of death or suicide, or suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Not everyone who is depressed experiences every symptom. Some people experience only a few symptoms while others may experience many. Several persistent symptoms in addition to low mood are required for a diagnosis of major depression, but people with only a few – but distressing – symptoms may benefit from treatment of their “subsyndromal” depression. The severity and frequency of symptoms and how long they last will vary depending on the individual and his or her particular illness. Symptoms may also vary depending on the stage of the illness.

Risk Factors

Depression is one of the most common mental disorders in the U.S. Current research suggests that depression is caused by a combination of genetic, biological, environmental, and psychological factors.

Depression can happen at any age, but often begins in adulthood. Depression is now recognized as occurring in children and adolescents, although it sometimes presents with more prominent irritability than low mood. Many chronic mood and anxiety disorders in adults begin as high levels of anxiety in children.

Depression, especially in midlife or older adults, can co-occur with other serious medical illnesses, such as diabetes, cancer, heart disease, and Parkinson’s disease. These conditions are often worse when depression is present. Sometimes medications taken for these physical illnesses may cause side effects that contribute to depression. A doctor experienced in treating these complicated illnesses can help work out the best treatment strategy.

Risk factors include:

  • Personal or family history of depression
  • Major life changes, trauma, or stress
  • Certain physical illnesses and medications

Treatment and Therapies

Depression, even the most severe cases, can be treated. The earlier that treatment can begin, the more effective it is. Depression is usually treated with medications, psychotherapy, or a combination of the two. If these treatments do not reduce symptoms, electroconvulsive therapy (ECT) and other brain stimulation therapies may be options to explore.

Quick Tip: No two people are affected the same way by depression and there is no "one-size-fits-all" for treatment. It may take some trial and error to find the treatment that works best for you.
Medications

Antidepressants are medicines that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has manageable side effects. A medication that has helped you or a close family member in the past will often be considered.

Antidepressants take time – usually 2 to 4 weeks – to work, and often, symptoms such as sleep, appetite, and concentration problems improve before mood lifts, so it is important to give medication a chance before reaching a conclusion about its effectiveness. If you begin taking antidepressants, do not stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and then stop taking the medication on their own, and the depression returns. When you and your doctor have decided it is time to stop the medication, usually after a course of 6 to 12 months, the doctor will help you slowly and safely decrease your dose. Stopping them abruptly can cause withdrawal symptoms.

Please Note: In some cases, children, teenagers, and young adults under 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. This warning from the U.S. Food and Drug Administration (FDA) also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

If you are considering taking an antidepressant and you are pregnant, planning to become pregnant, or breastfeeding, talk to your doctor about any increased health risks to you or your unborn or nursing child.

To find the latest information about antidepressants, talk to your doctor and visit www.fda.gov  .

You may have heard about an herbal medicine called St. John's wort. Although it is a top-selling botanical product, the FDA has not approved its use as an over-the-counter or prescription medicine for depression, and there are serious concerns about its safety (it should never be combined with a prescription antidepressant) and effectiveness. Do not use St. John’s wort before talking to your health care provider. Other natural products sold as dietary supplements, including omega-3 fatty acids and S-adenosylmethionine (SAMe), remain under study but have not yet been proven safe and effective for routine use. For more information on herbal and other complementary approaches and current research, please visit the National Center for Complementary and Integrative Health  website.

Brain Stimulation Therapies

If medications do not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an option to explore. Based on the latest research:

  • ECT can provide relief for people with severe depression who have not been able to feel better with other treatments.
  • Electroconvulsive therapy can be an effective treatment for depression. In some severe cases where a rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention.
  • Once strictly an inpatient procedure, today ECT is often performed on an outpatient basis. The treatment consists of a series of sessions, typically three times a week, for two to four weeks.
  • ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually these side effects are short-term, but sometimes memory problems can linger, especially for the months around the time of the treatment course. Advances in ECT devices and methods have made modern ECT safe and effective for the vast majority of patients. Talk to your doctor and make sure you understand the potential benefits and risks of the treatment before giving your informed consent to undergoing ECT.
  • ECT is not painful, and you cannot feel the electrical impulses. Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. Within one hour after the treatment session, which takes only a few minutes, the patient is awake and alert.

Other more recently introduced types of brain stimulation therapies used to treat medicine-resistant depression include repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS). Other types of brain stimulation treatments are under study. You can learn more about these therapies on the NIMH Brain Stimulation Therapies webpage.

If you think you may have depression, start by making an appointment to see your doctor or health care provider. This could be your primary care practitioner or a health provider who specializes in diagnosing and treating mental health conditions. Visit the NIMH Find Help for Mental Illnesses if you are unsure of where to start.

Psychotherapies

Several types of psychotherapy (also called “talk therapy” or, in a less specific form, counseling) can help people with depression. Examples of evidence-based approaches specific to the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy. More information on psychotherapy is available on the NIMH website and in the NIMH publication Depression: What You Need to Know.

Beyond Treatment: Things You Can Do

Here are other tips that may help you or a loved one during treatment for depression:

  • Try to be active and exercise.
  • Set realistic goals for yourself.
  • Try to spend time with other people and confide in a trusted friend or relative.
  • Try not to isolate yourself, and let others help you.
  • Expect your mood to improve gradually, not immediately.
  • Postpone important decisions, such as getting married or divorced, or changing jobs until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
  • Continue to educate yourself about depression.
Join a Study

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. During clinical trials, treatments might be new drugs or combinations of drugs, new psychotherapies or devices, or new ways to use existing treatments. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individual participants may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Please note: Decisions about whether to participate in a clinical trial and which ones are best suited for a given individual are best made in collaboration with your licensed health professional.
Clinical Trials at NIMH/NIH

Scientists at the NIMH campus conduct research on numerous areas of study, including cognition, genetics, epidemiology, and psychiatry. The studies take place at the NIH Clinical Center in Bethesda, Maryland and usually require regular visits. After an initial phone interview to see if any of the clinical trials recruiting subjects are a good match for you, you will come to an appointment at the clinic and meet with a clinician. Visit the NIMH Clinical Trials — Participants or Join a Study: Disruptive Mood Dysregulation Disorder for more information.

How do I find a Clinical Trials at NIMH on Depression?

Doctors at NIMH are dedicated to mental health research, including clinical trials of possible new treatments as well as studies to understand the causes and effects of depression. The studies take place at the NIH Clinical Center in Bethesda, Maryland and require regular visits. After the initial phone interview, you will come to an appointment at the clinic and meet with one of our clinicians. Find NIMH studies currently recruiting participants with depression by visiting Join a Research Study: Depression.

How Do I Find a Clinical Trial Near Me?

To search for a clinical trial near you, you can visit ClinicalTrials.gov  . This is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world (search: depression). ClinicalTrials.gov gives you information about a trial's purpose, who may participate, locations, and contact information for more details. This information should be used in conjunction with advice from health professionals.

Learn More
Free Booklets and Brochures
  • Chronic Illness & Mental Health: This brochure discusses chronic illnesses and depression, including symptoms, health effects, treatment, and recovery.
  • Depression and College Students: This brochure describes depression, treatment options, and how it affects college students.
  • Depression and Older Adults: Depression is not a normal part of aging. This brochure describes the signs, symptoms, and treatment options for depression in older adults.
  • Depression: What You Need to Know: This booklet contains information on depression including signs and symptoms, treatment and support options, and a listing of additional resources.
  • Postpartum Depression Facts: A brochure on postpartum depression that explains its causes, symptoms, treatments, and how to get help.
  • Teen Depression: This flier for teens describes depression and how it differs from regular sadness. It also describes symptoms, causes, and treatments, with information on getting help and coping.
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Persistent Depressive Disorder (Dysthymia)

Individuals diagnosed with persistent depressive disorder for two years, most days and majority of the day, have experienced depressed mood and other symptoms such as low self-esteem, feelings of hopelessness, fatigue, lack of concentration, and disturbance in eating and sleep. The symptoms have caused significant disruption in everyday activities and responsibilities, such as in the home, relationships, work, and school (DSM-5, 2013; Sue, et. al., 2013; Comer, 2014). According to DSM-5 (2013), the diagnostic criteria for persistent depressive disorder are:

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

  • Poor appetite or overeating.
  • Insomnia or hypersomnia.
  • Low energy or fatigue.
  • Low self-esteem.
  • Poor concentration or difficulty making decisions.
  • Feelings of hopelessness.

C. During the 2-year period (one year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for two years.

E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

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

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

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Premenstrual Dysphoric Disorder

Individuals diagnosed with premenstrual dysphoric disorder, during the week before menstruation in a one-year period, have experienced severe symptoms (e.g., irritability, anxiety, sadness, disturbance in eating and sleep, fatigue, lack of concentration) that caused significant disruption in everyday activities and responsibilities, such as in the home, relationships, work, and school (DSM-5, 2013; Sue, et. al., 2013; Comer, 2014). According to DSM-5 (2013), the diagnostic criteria for premenstrual dysphoric disorder are:

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

B. One (or more) of the following symptoms must be present:

  • Marked affective lability (e.g., mood swings: feeling suddenly sad or tearful, or increased sensitivity to rejection).
  • Marked irritability or anger or increased interpersonal conflicts.
  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
  • Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.

  • Decreased interest in usual activities (e.g., work, school, friends, hobbies).
  • Subjective difficulty in concentration.
  • Lethargy, easy fatigability, or marked lack of energy.
  • Marked change in appetite; overeating; or specific food cravings.
  • Hypersomnia or insomnia.
  • A sense of being overwhelmed or out of control.
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.

Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.

D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).

E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

 
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Explanations for the Causes and Risk Factors of Depressive Disorders

It is believed that both the individual’s genetic predisposition and environmental factors contribute to the development of depressive disorders (Sue, et. al., 2013; Comer, 2014).

Biological Explanations

According to the biological theory, biochemical imbalance, a person’s heredity (genetic predisposition), and brain structures may play a role in the development of an anxiety disorder.

 

Biochemical Factors

Biochemical factors involve neurotransmitters and hormones. Neurotransmitters are chemicals in the nervous system that process and transmit information. Hormones are messengers produced by glands in the endocrine system (DSM-5, 2013; Sue, et. al., 2013; Comer, 2014).

The two most widely studied neurotransmitters associated with depressive disorders are norepinephrine and serotonin. It is assumed that depressive disorders are caused by diminished production and/or low activity of norepinephrine and serotonin.

Recent studies have implicated cortisol and melatonin (two hormones produced by the endocrine system) in the development of depressive disorders.

  • In response to stress, individuals diagnosed with depressive disorders produce much higher levels of cortisol compared those without the diagnosis. Cortisol hormone is produced by adrenal glands in response to environmental demand (Sue, et. al., 2013; Comer, 2014).
  • People diagnosed with seasonal affective disorder secrete a higher level of melatonin in the winter. Melatonin is produced by the pineal gland (Sue, et. al., 2013; Comer, 2014).
   

Brain Structure and Functions

Brain imagining studies have supported a link between the diagnosis of depressive disorders and irregularity in the brain structures and their activities. Particularly, it appears that the brain structures that are involved in emotional responses are smaller in people diagnosed with depressive disorders (such as the hippocampus, which is associated with emotions and memory). Furthermore, there is the suggestion of abnormal blood flow and activity in several regions of the brain (Sue, et. al., 2013; Comer, 2014).

   
 

Genetic Factors

Thre types of biological research methods—twin, adoptive, family linkage analysis, and molecular biology gene studies—have highlighted the role of heredity in the development of depressive disorders (DSM-5, 2013; Sue, et. al., 2013; Comer, 2014). Specifically:

  • Relatives of people diagnosed with depressive disorders have a 20 percent chance of developing the disorder, compared to less than 10 percent in relatives of those without the diagnosis (Kamali & McInnis, 2011; Berrettini, 2006, McGuffin et. al., 2006).
  • In monozygotic twins (identical twins), if one is diagnosed with a depressive disorder, the other twin will have a 46 percent chance to develop the disorder compared to dizygotic twins (Fraternal twins), who have a 20 percent chance of developing the disorder (McGuffin et. al., 2006).
  • Molecular biology gene studies have indicated an abnormality in the 5-HTT gene located on chromosome 17 in people diagnosed with depressive disorders. The significance of this chromosome and the 5-HTT gene include: (1) their association with the release of increased amount of cortisol which is a stress hormone; (2) disturbance in serotonin activity and circulation; and (3) alteration in brain structures such as increased size of thalamus in people diagnosed with depressive disorders (Sue, et. al., 2013; Comer, 2014).
     

Psychological Explanations

Psychodynamic/Psychoanalytic Explanation

According to Sue, et. al. (2013) and Comer (2014), psychodynamic theorists view the causes of depressive disorders as the following three issues:

  • Anger turned inward in case of a loss — the anger from feeling abandoned by the loss object cannot be expressed externally and thus it becomes internal. The loss could be death, end of a relationship, or being laid off. For example, in case of death, the loss object is a parent or a friend who died.
  • Excessive dependence on others for self-esteem.
  • Helplessness at achieving one's goals.

Cognitive Explanation

According to the cognitive theory, people diagnosed with depressive disorders engage in distorted and negatively biased thinking. The two main cognitively-based perspectives are Aaron Beck's cognitive distortion model, and Martin Seligman's attribution and learned helplessness theory (Sue, et. al., 2013; Comer, 2014).

Aaron Beck's Cognitive Distortion Model

In his theory, Beck views depression as the result of people's negative and distorted processes that include:

  • Negative schemas that are the individual's lens for the incoming information.
  • Systematic errors in logic in the way that the incoming information is processed and interpreted by the individual.
  • Cognitive triads, which are the long-lasting views that persons hold about themselves, their environment, and their future. Beck assumes that the triads are developed during childhood in response to negative experiences.
   

Martin Seligman’s Attribution and Learned Theory

Seligman views expectation as the contributing factor to the development of depressive disorders (Sue, et. al., 2013; Comer, 2014). That is, the depressed individual expects that:

  • Adverse experiences and/or situations are internally caused rather than externally. That is, he causes the awful things that happen in his life and there is nothing he can do to prevent them from happening.
  • Adverse experiences and/or situations are global rather than specific. That is, the awful things that happen to him will affect everything and not just one area.
  • Adverse experiences and/or situations are stable rather than unstable and short–lived. That is, the awful things that happen in his life will continue to happen to him because they are stable over time.
 

Behavioral Explanation

According to the behavioral model, the symptoms of depression are learned through operant conditioning and modeling or observational learning (Sue, et. al., 2013; Comer, 2014). Peter Lowinsohn's behavioral theory views lack of rewards or reinforcements as the cause of depressive disorders. That is, people diagnosed with these disorders may generally receive fewer rewards or reinforcements than individuals without the diagnosis. The lack of reinforcement results in reduced activities that could bring rewarding consequences (Sue, et. al., 2013; Comer, 2014). For instance, a man who has not been granted even one interview in the last six months, despite his submission of one-hundred applications may be discouraged and not apply for a position that he is qualified for, even if he has a high probability of getting an interview.

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Explanations for the Tratment of Depressive Disorders

   

Medications (Information from National Institute of Mental Health)

Biological treatments generally include antidepressant medications that balance the neurotransmitters serotonin, norepinephrine, and dopamine. In cases in which people do not respond to medication, electroconvulsive or brain stimulation is used to increase the activity level of neurotransmitters (Sue, et. al., 2013; Comer, 2014).

Antidepressants

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRI's). These include:

  • Fluoxetine (Prozac)
  • Citalopram (Celexa)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Escitalopram (Lexapro)

Other types of medications are serotonin and norepinephrine reuptake inhibitors (SNRI's). SNRI's are similar to SSRI's and include venlafaxine (Effexor) and duloxetine (Cymbalta).

Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRI's and s are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOI's). For some people, tricyclics, tetracyclics, or MAOI's may be the best medications.

   

Side Effects

Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately. The most common side effects associated with SSRI's and SNRI's include:

  • Headache, which usually goes away within a few days.
  • Nausea (feeling sick to your stomach), which usually goes away within a few days.
  • Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken may need to be changed.
  • Needs to be adjusted to help lessen these side effects.
  • Agitation (feeling jittery).
  • Sexual problems, which can affect both men and women, and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

  • Dry mouth.
  • Constipation.
  • Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
  • Sexual problems, which can affect both men and women, and may include reduced sex drive, and problems having and enjoying sex.
  • Blurred vision, which usually goes away quickly.
  • Drowsiness. Usually antidepressants that make you drowsy are taken at bedtime.

People taking MAOI's need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOI's. Tyramine is found in some cheeses, wines, and pickles. This chemical is also in some medications, including decongestants and over-the-counter cold medicine. Mixing MAOI's and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOI's should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken? People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better, stop taking the medication too soon, and their depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked", on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by National Institute of Mental Health (NIMH) found that if a person with difficult-to-treat depression did not get better with his or her first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).

Are herbal medicines used to treat depression? The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health conducted a clinical trial to determine the effectiveness of treating adults who have major depression with St. John's wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI, and one-third took a placebo, or "sugar pill". The people did not know what they were taking. The study found that St. John's wort was no more effective than the placebo in treating major depression. A study currently in progress is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can dangerously interact with other medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. John's wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

Cognitively-Based Treatments

Successful cognitive-behavioral therapy assists clients to identify and deal with the source of their emotional stress through education, cognitive modification, and teaching healthy behavior and coping skills (Sue, et. al., 2013; Comer, 2014). Specifically, clients learn to:

  • Identify negative and distorted thoughts and logic.
  • Recognize the link between the negative and distorted thoughts and the feelings that follow.
  • Evaluate the accuracy and validity of the negative and distorted thoughts.
  • Modify and restructure the distorted thought processes into accurate and adaptive ones.
  • Try new behaviors and activities.
  • Engage in activities that have shown to be rewarding and can elevate mood.
   
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Bipolar Disorders

In the newly published Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5, 2013), bipolar and related disorders are discussed in a category by themselves. This is in contrast to DSM-IV-R, where they were a part of mood disorders.

Information from Depression and Bipolar Support Alliance (DBSA)

  • Bipolar disorder affects approximately 5.7 million adult Americans, or about 2.6% of the U.S. population age 18 and older every year. (National Institute of Mental Health)
  • The median age of onset for bipolar disorder is 25 years (National Institue of Mental Health), although the illness can start in early childhood or as late as the 40's and 50's.
  • An equal number of men and women develop bipolar illness and it is found in all ages, races, ethnic groups and social classes.
  • More than two-thirds of people with bipolar disorder have at least one close relative with the illness or with unipolar major depression, indicating that the disease has a heritable component. (National Institute of Mental Health)
  • Although bipolar disorder is equally common in women and men, research indicates that approximately three times as many women as men experience rapid cycling. (Journal of Clinical Psychiatry, 58, 1995 [Suppl.15])
  • Bipolar disorder is the sixth leading cause of disability in the world. (World Health Organization)
  • Bipolar disorder results in 9.2 years reduction in expected life span, and as many as one in five patients with bipolar disorder completes suicide. (National Institute of Mental Health)
  • Bipolar disorder is more likely to affect the children of parents who have the disorder. When one parent has bipolar disorder, the risk to each child is l5 to 30%. When both parents have bipolar disorder, the risk increases to 50 to 75%. (National Institute of Mental Health)
  • Bipolar Disorder may be at least as common among youth as among adults. In a recent NIMH study, one percent of adolescents ages 14 to 18 were found to have met criteria for bipolar disorder or cyclothymia in their lifetime. (National Institute of Mental Health)
  • Some 20% of adolescents with major depression develop bipolar disorder within five years of the onset of depression. (Birmaher, B., "Childhood and Adolescent Depression: A Review of the Past 10 Years." Part I, 1995)
  • Up to one-third of the 3.4 million children and adolescents with depression in the United States may actually be experiencing the early onset of bipolar disorder. (American Academy of Child and Adolescent Psychiatry, 1997)
  • When manic, children and adolescents, in contrast to adults, are more likely to be irritable and prone to destructive outbursts than to be elated or euphoric. (National Institute of Mental Health).

On this page, we will discuss bipolar I, bipolar II and cyclothymic disorder.

 
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Bipolar I Disorder

According to DSM-5 (2013), individuals diagnosed with bipolar I disorder have met the criteria for at least one manic episode in their lifetime. A manic episode is defined as a distinct period of at least one week, where nearly every day the individual displays extreme elevation in mood, irritability and energy. In addition, three or more of the following symptoms are present – the requirement increases to four, if the mood is only irritable. These symptoms significantly cause disturbance in the individual's capacity to function in personal, academic, work and social settings. According to DSM-5 (2013), the diagnostic criteria for bipolar disorder I are:

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.

Bipolar II Disorder

According to DSM-5 (2013), individuals diagnosed with bipolar II disorder have met the criteria for at least one or more major depressive episodes and at least one hypomanic episode.

Manic Episode

According to DSM-5 (2013), the diagnostic criteria for a manic episode are:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

  • Inflated self-esteem or grandiosity.
  • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  • More talkative than usual or pressure to keep talking.
  • Flight of ideas or subjective experience that thoughts are racing.
  • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
  • Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

Hypomanic Episode

According to DSM-5 (2013), the diagnostic criteria for a hypomanic episode are:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree:

  • Inflated self-esteem or grandiosity.
  • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
  • More talkative than usual or pressure to keep talking.
  • Flight of ideas or subjective experience that thoughts are racing.
  • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
  • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
  • Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is not characteristic of the individual when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).

Note: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Major Depressive Episode

According to DSM-5 (2013), the diagnostic criteria for a major depressive episode are:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

  • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  • Insomnia or hypersomnia nearly every day.
  • Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
  • Fatigue or loss of energy nearly every day.
  • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

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

C. The episode is not attributable to the physiological effects of a substance or another medical condition.

Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode” above).

B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

Great Videos and Information on Disruptive Mood Dysregulation Disorder from NIMH
 
 
 

 

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Cyclothymic Disorder

Individuals diagnosed with cyclothymic disorder have experienced numerous hypomanic (such as irritability, elevated mood, grandiosity, lack of need for food or sleep) and depressive (depressed mood, low self-esteem, feelings of hopelessness, fatigue, lack of concentration) episodes. The symptoms have lasted majority of the day, more days than not during a two-year period. These symptoms significantly cause disturbance in the individual's capacity to function in personal, academic, work and social settings. According to DSM-5 (2013), the diagnostic criteria for cyclothymic disorder are:

A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.

C. Criteria for a major depressive, manic, or hypomanic episode have never been met.

D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

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

 
 
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Explanations for the Causes and Risk Factors of Depressive Disorders

It is believed that both the individual’s genetic predisposition and environmental factors contribute to the development of depressive disorders (Sue, et. al., 2013; Comer, 2014).

Biological Explanations

According to the biological theory, biochemical imbalance, a person’s heredity (genetic predisposition), and brain structures may play a role in the development of an anxiety disorder.

 

Biochemical Factors

Biochemical factors involve neurotransmitters and hormones. Neurotransmitters are chemicals in the nervous system that process and transmit information. Hormones are messengers produced by glands in the endocrine system (DSM-5, 2013; Sue, et. al., 2013; Comer, 2014).

The two most widely studied neurotransmitters associated with depressive disorders are norepinephrine and serotonin. It is assumed that depressive disorders are caused by diminished production and/or low activity of norepinephrine and serotonin.

Recent studies have implicated cortisol and melatonin (two hormones produced by the endocrine system) in the development of depressive disorders.

  • In response to stress, individuals diagnosed with depressive disorders produce much higher levels of cortisol compared those without the diagnosis. Cortisol hormone is produced by adrenal glands in response to environmental demand (Sue, et. al., 2013; Comer, 2014).
  • People diagnosed with seasonal affective disorder secrete a higher level of melatonin in the winter. Melatonin is produced by the pineal gland (Sue, et. al., 2013; Comer, 2014).
   

Brain Structure and Functions

Brain imagining studies have supported a link between the diagnosis of depressive disorders and irregularity in the brain structures and their activities. Particularly, it appears that the brain structures that are involved in emotional responses are smaller in people diagnosed with depressive disorders (such as the hippocampus, which is associated with emotions and memory). Furthermore, there is the suggestion of abnormal blood flow and activity in several regions of the brain (Sue, et. al., 2013; Comer, 2014).

   
 

Genetic Factors

Three types of biological research methods—twin, adoptive, family linkage analysis, and molecular biology gene studies—have highlighted the role of heredity in the development of depressive disorders (DSM-5, 2013; Sue, et. al., 2013; Comer, 2014). Specifically:

  • Relatives of people diagnosed with depressive disorders have a 20 percent chance of developing the disorder, compared to less than 10 percent in relatives of those without the diagnosis (Kamali & McInnis, 2011; Berrettini, 2006, McGuffin et. al., 2006).
  • In monozygotic twins (identical twins), if one is diagnosed with a depressive disorder, the other twin will have a 46 percent chance to develop the disorder compared to dizygotic twins (Fraternal twins), who have a 20 percent chance of developing the disorder (McGuffin et. al., 2006).
  • Molecular biology gene studies have indicated an abnormality in the 5-HTT gene located on chromosome 17 in people diagnosed with depressive disorders. The significance of this chromosome and the 5-HTT gene include: (1) their association with the release of increased amount of cortisol which is a stress hormone; (2) disturbance in serotonin activity and circulation; and (3) alteration in brain structures such as increased size of thalamus in people diagnosed with depressive disorders (Sue, et. al., 2013; Comer, 2014).
     

Psychological Explanations

Psychodynamic/Psychoanalytic Explanation

According to Sue, et. al. (2013) and Comer (2014), psychodynamic theorists view the causes of depressive disorders as the following three issues:

  • Anger turned inward in case of a loss — the anger from feeling abandoned by the loss object cannot be expressed externally and thus it becomes internal. The loss could be death, end of a relationship, or being laid off. For example, in case of death, the loss object is a parent or a friend who died.
  • Excessive dependence on others for self-esteem.
  • Helplessness at achieving one's goals.

Cognitive Explanation

According to the cognitive theory, people diagnosed with depressive disorders engage in distorted and negatively biased thinking. The two main cognitively-based perspectives are Aaron Beck's cognitive distortion model, and Martin Seligman's attribution and learned helplessness theory (Sue, et. al., 2013; Comer, 2014).

Aaron Beck's Cognitive Distortion Model

In his theory, Beck views depression as the result of people's negative and distorted processes that include:

  • Negative schemas that are the individual's lens for the incoming information.
  • Systematic errors in logic in the way that the incoming information is processed and interpreted by the individual.
  • Cognitive triads, which are the long-lasting views that persons hold about themselves, their environment, and their future. Beck assumes that the triads are developed during childhood in response to negative experiences.
   

Martin Seligman’s Attribution and Learned Theory

Seligman views expectation as the contributing factor to the development of depressive disorders (Sue, et. al., 2013; Comer, 2014). That is, the depressed individual expects that:

  • Adverse experiences and/or situations are internally caused rather than externally. That is, he causes the awful things that happen in his life and there is nothing he can do to prevent them from happening.
  • Adverse experiences and/or situations are global rather than specific. That is, the awful things that happen to him will affect everything and not just one area.
  • Adverse experiences and/or situations are stable rather than unstable and short–lived. That is, the awful things that happen in his life will continue to happen to him because they are stable over time.
 

Behavioral Explanation

According to the behavioral model, the symptoms of depression are learned through operant conditioning and modeling or observational learning (Sue, et. al., 2013; Comer, 2014). Peter Lowinsohn's behavioral theory views lack of rewards or reinforcements as the cause of depressive disorders. That is, people diagnosed with these disorders may generally receive fewer rewards or reinforcements than individuals without the diagnosis. The lack of reinforcement results in reduced activities that could bring rewarding consequences (Sue, et. al., 2013; Comer, 2014). For instance, a man who has not been granted even one interview in the last six months, despite his submission of one-hundred applications may be discouraged and not apply for a position that he is qualified for, even if he has a high probability of getting an interview.

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Explanations for the Tratment of Depressive Disorders

   

Medications (Information from National Institute of Mental Health)

Biological treatments generally include antidepressant medications that balance the neurotransmitters serotonin, norepinephrine, and dopamine. In cases in which people do not respond to medication, electroconvulsive or brain stimulation is used to increase the activity level of neurotransmitters (Sue, et. al., 2013; Comer, 2014).

Antidepressants

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRI's). These include:

  • Fluoxetine (Prozac)
  • Citalopram (Celexa)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Escitalopram (Lexapro)

Other types of medications are serotonin and norepinephrine reuptake inhibitors (SNRI's). SNRI's are similar to SSRI's and include venlafaxine (Effexor) and duloxetine (Cymbalta).

Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRI's are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOI's). For some people, tricyclics, tetracyclics, or MAOI's may be the best medications.

   

Side Effects

Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately. The most common side effects associated with SSRI's and SNRI's include:

  • Headache, which usually goes away within a few days.
  • Nausea (feeling sick to your stomach), which usually goes away within a few days.
  • Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken may need to be changed.
  • Needs to be adjusted to help lessen these side effects.
  • Agitation (feeling jittery).
  • Sexual problems, which can affect both men and women, and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

  • Dry mouth.
  • Constipation.
  • Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
  • Sexual problems, which can affect both men and women, and may include reduced sex drive, and problems having and enjoying sex.
  • Blurred vision, which usually goes away quickly.
  • Drowsiness. Usually antidepressants that make you drowsy are taken at bedtime.

People taking MAOI's need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOI's. Tyramine is found in some cheeses, wines, and pickles. This chemical is also in some medications, including decongestants and over-the-counter cold medicine. Mixing MAOI's and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOI's should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken? People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better, stop taking the medication too soon, and their depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked", on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by National Institute of Mental Health (NIMH) found that if a person with difficult-to-treat depression did not get better with his or her first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).

Are herbal medicines used to treat depression? The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health conducted a clinical trial to determine the effectiveness of treating adults who have major depression with St. John's wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI, and one-third took a placebo, or "sugar pill". The people did not know what they were taking. The study found that St. John's wort was no more effective than the placebo in treating major depression. A study currently in progress is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can dangerously interact with other medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. John's wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

Cognitively-Based Treatments

Successful cognitive-behavioral therapy assists clients to identify and deal with the source of their emotional stress through education, cognitive modification, and teaching healthy behavior and coping skills (Sue, et. al., 2013; Comer, 2014). Specifically, clients learn to:

  • Identify negative and distorted thoughts and logic.
  • Recognize the link between the negative and distorted thoughts and the feelings that follow.
  • Evaluate the accuracy and validity of the negative and distorted thoughts.
  • Modify and restructure the distorted thought processes into accurate and adaptive ones.
  • Try new behaviors and activities.
  • Engage in activities that have shown to be rewarding and can elevate mood.
   
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Behavioral Health Treatment Services Locator

Behavioral Health Treatment Services Locator By entering your zip code at findtreatment.samhsa.gov, you can quickly find alcohol and drug abuse treatment or mental health treatment facilities in your area. This service is courtesy of the Substance Abuse and Mental Health Services Administration (SAMHSA) which works to "to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services." (SAMHSA)

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