Mood Disorders

On this page we want to talk about some of the important distinctions we try to make during a typical consultation. In other words, when we see someone with "depression", we find it is important to delve a bit deeper and understand the type of depression. These are some of the distinctions that we are interested in...

Depression and Mood Cycles

Since the beginning of psychiatry there has been controversy in the field about the question of whether depression (unipolar depression) and bipolar depression are different conditions. Let's begin with a definition of "bipolar depression." Bipolar depression is defined in the current psychiatric manual as depression in someone who has ever experienced a significant energized period (also known as hypomania or mania). Most people (and most doctors) who have any idea of what the words "bipolar" and "mania" mean tend to think of the extreme examples of someone up all night for days on end and acting like a "maniac."

Recently, though, there has been greater recognition that the so-called "typical" energized state may actually be something that never happens to most bipolar individuals. These people have either cyclothymia or bipolar disorder type II. For them the "energized" state is not only not something that is obviously pathological but it may, in fact, be routinely a very productive state, they may, in fact, rely on these bursts of energy to keep up with work or to finish creative projects. We have included some thoughts about this energized state in a page entitled "hypomania" (literally "a little mania") which is the technical term for these states of being.

The evidence, however, still suggests that the depression of those with these milder forms of bipolar disorder responds differently to treatment, and thus it is important to identify these productive energized states. One resource that we have found useful is a questionnaire developed by Ronald Pies and modified by S. Nassir Ghaemi called the Bipolar Spectrum Disorders Questionnaire. A copy of this is attached on this website by kind permission of Dr. Ghaemi.

Depression and Anxiety

Another important question that is part of nearly every consultation we do is the relationship between mood symptoms and anxiety. We spend a fair amount of time in the clinic trying to distinguish between the agitation and racing thoughts associated with anxiety, as contrasted with the agitation and racing thoughts associated with being energized or hypomanic, and as further contrasted with the kind of agitation that can be present in severe depression.

One of the reasons that we do this is because there is evidence to suggest that the difference between anxiety and mood symptoms is significant in terms of which treatment approaches are the most successful. Specifically, many of the treatments for anxiety that work the best in the short run (benzodiazepines, like lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium), etc.) are not the best treatments long term for anxiety. Studies now demonstrate that for many types of anxiety medication treatment is not as effective as psychotherapy. Therapy treatment leads to significant long term benefits after the treatment is discontinued. The benefits from medication treatment of anxiety generally don't last beyond the time that the medications are being taken. In the case of benzodiazepines, there may be adverse affects from taking the medications long term that could be significant (for instance some people may be at increased risk to abusing substances when taking these medications, also medications may disrupt sleep, and, more controversially, there is some evidence that suggests that these medications may have adverse affects on memory when taken long term).

By contrast, as we have noted elsewhere in the section on medications, treatment of mood symptoms with medication seems to be associated with improvements in cognitive function and may be associated with long term benefits to brain function (there is evidence that antidepressants and mood stabilizers enhance
levels of Brain Derived Neurotrophic Factor which is a natural stimulant to neuron growth). It is not that psychotherapy isn't useful for mood disorders, but, in our experience, the mood disorder medications are often essential to treatment and psychotherapy may only be possible and effective after medication treatment is begun.

On the Mood States and Anxiety page we will talk some more about ways of distinguishing between the two, and the types of anxiety that are most important.

Conditions that Can Present with Depression

There are many non-psychiatric conditions that may present with some or all of the symptoms of depression. The complete list would be extraordinarily long (part of the reason we always get a very comprehensive medical history as part of our evaluation), but there are a few that are particularly significant:

Thyroid disorders

Disorders of sex hormones in men or women

Stress hormone disorders

Vitamin and mineral deficiencies

Anemia

Certain infections

Adverse affects from medications

Other medical conditions

Our screening questionnaire includes a number of questions designed to help us identify the possibilities that need to be evaluated the most carefully. Depending on what we find, we usually order laboratory and other studies to make sure that significant medical disorders are identified and treated properly.

Mood and Emotion

One of the questions that people often wonder is, "aren't these feelings that I am having normal." We find that we often can't answer that question. Instead we tend to wonder "are these feelings becoming an obstacle to getting where I want or need to go with my life?"

However exploring how well emotions are "functioning" can seem a bit soulless. Is that really the point. Aren't feelings more essential to our selves than that would suggest? We don't have good answers to those concerns. But this page on mood and emotion may be of interest to you.

The Neurobiology of Emotion

We have begun trying to integrate some of the important recent studies that are beginning to clarify the relationship between normal mood, mood disorders, and brain function. This page is clearly a work in progress.