Mood Disorders and Normal Mood
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 manual1 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 (mania) may actually be something that never happens to most bipolar individuals2. 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 energized.
The evidence suggests that the depression of those with these milder forms of bipolar disorder responds differently to treatment, and thus it is important to identify people with depression who also have 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 Questionnaire3. 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 is what is the relationship between mood symptoms and anxiety. We try hard to distinguish between agitation and “racing thoughts” associated with anxiety, as opposed to the agitation and racing thoughts associated with being energized or hypomanic.
There is evidence that the difference between anxiety and mood symptoms is significant in terms of which treatment approaches are the most successful. For anxiety, we often focus on psychotherapeutic approaches, at least in the long term, because long term treatment with many of the medications used to treat anxiety has significant adverse effects and, for many people, anxiety treatment with medication is not as effective as psychotherapy. Also psychotherapy treatment of anxiety 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 taken4.
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)5. 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
- 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.
1. Diagnostic and Statistical Manual – Text Revision (DSM IV-TR). American Psychiatric Association. Washington, DC: 2000.
2. Benazzi F, “Bipolar II disorder : epidemiology, diagnosis and management.” CNS Drugs. 2007;21(9):727-40.
3. Hirschfeld RM, Williams JB, Spitzer RL, et al. “Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire.”Am J Psychiatry. 2000 Nov;157(11):1873-5.
4. Gould RA, Otto MW, Pollack MH et al. “Cognitive behavioral and pharmacological treatment of generalized anxiety disorder: A preliminary meta-analysis.” Behavior Therapy Volume 28, Issue 2, 1997, Pages 285-305
5. Yoshimura R, Mitoma M, Sugita A, et al. “Effects of paroxetine or milnacipran on serum brain-derived neurotrophic factor in depressed patients.” Progress in Neuro-Psychopharmacology and Biological Psychiatry. Volume 31, Issue 5, 30 June 2007, Pages 1034-1037