Chapter 10 – Depressive and Bipolar Disorder
Mood disorder: a disorder in which the subject suffers from extreme, persistent, or poorly
regulated emotional states. DSM-5 mood disorders include disruptive mood dysregulation
disorder, major depressive disorder, persistent depressive disorder, and bipolar disorder.
• Mood is defined as a feeling or emotion.
• Mood disorders are one of the most common, chronic and disabling illnesses.
Overview of mood disorders
Dysphoria: a negative mood state characterized by prolonged bouts of sadness.
Anhedonia: a negative mood state characterized by a lack of enjoyment in anything one does and
a loss of interest in nearly all activities.
Irritability: a common symptom of major depressive disorder and disruptive mood
dysregulation disorder characterized by easy annoyance and touchiness, an angry mood, and
temper outbursts.
Mania: an abnormally elevated or expansive mood, increased goal-directed activity and energy,
and feelings of euphoria: an exaggerated sense of well-being.
• People with mania suffer from an ongoing combination of extreme highs and lows, a
condition known as bipolar disorder (BP) or manic-depressive illness.
2 major types of mood disorders in the DSM-5 are depressive disorders and bipolar disorders.
Overview of Mood Disorders – Section Summary
- Children with mood disorders suffer from extreme, persistent, or poorly regulated emotional
states – for example, excessive unhappiness, irritability, or swings in mood from deep sadness to
high elation.
- Mood disorders are common and are among the most persistent and disabling illnesses in young people.
- There are two major types of mood disorders: depressive disorders and bipolar disorders (BP).
Depressive disorders
Children who are depressed cannot seem to shake their sadness, and it will interfere with their
daily routines, social relationships, school performance, and overall functioning.
• Often accompanied by anxiety or ODD/CD.
History
It was thought that children express depression in a much different way than adults: masked
depression. But in reality, depression in children is not masked, but it may be overlooked
because it frequently co-occurs with more visible disorders, like conduct problems.
Depression in young people and development
90% of youths with depression show significant impairment in their daily functions.
Depression in children under 7 years is diffuse and less easily identified. The least is known
about depression in infants.
• Depressed preschool children may appear extremely somber and tearful. Negative and
self-destructive verbalization may occur, and physical complaints are common.
• Depressed school-age children display the same symptoms as preschoolers in addition to
increased irritability, disruptive behavior, temper tantrums, and combativeness.
• Depressed preteens and teens display the same symptoms as younger children, in
addition to increasing self-blame and expression of low self-esteem, persistent sadness,
and social inhibition.
,Depression as a symptom: refers to feeling sad or miserable.
Depression as a syndrome: refers to a group of symptoms that occur together more often than
by chance. The child may also display a reduced interest or pleasure in activities, cognitive and
motivational changes, and somatic and psychomotor changes.
Several forms of depression as a disorder:
1. Major depressive disorder (MDD): characterized by 5 or more mood, cognitive,
psychomotor, or somatic symptoms that have been present during the same 2-week
period. At least one of the symptoms is either depressed mood most of the day, nearly
every day, or markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day.
2. Persistent depressive disorder (P-DD): associated with depressed or irritable mood;
generally fewer, less severs, but longer-lasting symptoms than seen in MDD; and
significant impairment in functioning.
3. Disruptive mood dysregulation disorder (DMDD): characterized by:
1. Frequent and severe outbursts that are extreme over-reactions to the situation or provocation.
2. Chronic, persistently irritable or angry mood that is present between the severe
temper outbursts.
Depressive Disorders – Section Summary
- Depression in younger people involves numerous and persistent symptoms, including
impairments in mood, behavior, attitudes, thinking, and physical functioning.
- For a long time, it was mistakenly believed that depression did not exist in children in a form
comparable to depression in adults.
- It is now known that depression in young people is prevalent, disabling, and often under-referred.
- The way in which children express and experience depression changes with age.
- It is important to distinguish between depression as a symptom, a syndrome, and a disorder.
- 3 types of DSM-5 depressive disorders are MDD, P-DD, and DMDD.
Major depressive disorder (MDD)
Key features of MDD: sadness, loss of interest/pleasure in nearly all activities, irritability, plus a
number of specific symptoms that are present during the same 2-week period.
3 important points about the diagnosis of MDD in children and adolescents:
• The same DSM-5 criteria for diagnosing adults can be used to diagnose school-age
children and adolescents.
• Because children’s disruptive behaviors attract more attention or are more easily observed
as compared with internal suffering, depression in children can be easily overlooked.
• Some features of depression are likely more common in children and adolescents than in
adults, notably, irritable mood.
Prevalence
• 2-8% of all youths aged 4-18 experience MDD each year.
• Relatively rare among preschool and school-age children (1-3%).
• Lifetime prevalence estimates a range from 11-20%.
Comorbidity
90% of young people with depression have one or more disorders, and 50% have 2 or more.
• Most frequent co-occurring disorders with MDD are anxiety disorders (generalized
anxiety in particular), specific phobias, and separation anxiety disorders (SAD).
o Early anxiety disorder is a strong predictor or later depression.
• Other common co-occurring disorders: P-DD, conduct problems, ADHD, and substance-
use disorder (SUD).
, • 60% of adolescents with MDD have a comorbid personality disorders, most commonly
borderline personality disorders.
Onset, course, and outcome
• Onset usually between 13-15 years.
• MDD has a chance of recurrence of about 25% within 1 year, 40% within 2 years and
70% within 5 years.
• Those with onset prior to age 15 and recurrent episode prior to age 20 display more
severe, chronic, suicidal depressions; greater co-occurring anxiety and worse social
functioning at age 15; and poorer psychosocial outcomes at age 20.
• 1/3 of adolescents with MDD will develop a BP after the onset of their depression,
known as bipolar switch.
Gender
Females are twice as likely as males to suffer from depression, are more susceptible to milder
mood disorders, and are more likely to experience recurrent episodes.
• Sex difference not present among children 6-11 years.
• Symptom presentation is generally quite similar for both sexes.
Possible reasons that put girls at a disadvantage during adolescents:
• Hormonal changes in estrogen and testosterone may affect brain function, increasing
sexual maturity may affect social roles, etc.
• Girls have a greater orientation toward cooperation and sociality. They also use ruminative
coping styles to deal with stress (focusing on the symptoms of distress and its causes rather
than on solutions), especially stress involving interpersonal loss and disruptions.
Ethnicity and culture
The incidence of depression has been found to vary across regions worldwide, however, few
studies have examined ethnic, racial, or cultural differences in clinically depressed youths, and
findings have been inconsistent.
Major Depressive Disorder (MDD) – Section Summary
- The key features of MDD are sadness, loss of interest or pleasure in nearly all activities, and
irritability, plus many specific symptoms that are present for at least 2 weeks.
- The overall prevalence of MDD annually for youths 4-18 years of age is between 2-8% with rates
that are low during childhood but increase dramatically during adolescence. The likelihood that a
youth has ever had MDD is higher, from 10-20% or more.
- The most frequent accompanying disorders in young people with MDD are anxiety disorder, P-
DD, conduct problems, ADHD, and substance-use disorder.
- Almost all young people recover from their initial depressive episode, but about 60% have
another episode within 5 years and many develop BP.
- Depression in preadolescent children is equally common in boys and girls, but the ratio of girls to
boys is about 2:1 to 3:1 after puberty.
- The relationship between depression and race/ethnicity during childhood and adolescence is an
understudied area.
Persistent depressive disorder (P-DD) (Dysthymia)
Although the symptoms of P-DD are chronic, they are less severe than those for children with MDD.
Children with P-DD are characterized by poor emotion regulation, which includes constant
feelings of sadness, being unloved and forlorn, self-deprecation, low self-esteem, anxiety, anger,
and temper tantrums.
