Major mood disorders

In general, two major, or severe, mood disorders are recognized: bipolar disorder and major depression.

Bipolar disorder (previously known as manic-depressive disorder) is characterized by an elated or euphoric mood, quickened thought and accelerated, loud, or voluble speech, overoptimism and heightened enthusiasm and confidence, inflated self-esteem, heightened motor activity, irritability, excitement, and a decreased need for sleep. Depressive mood swings typically occur more often and last longer than manic ones, though there are persons who have episodes only of mania. Individuals with bipolar disorder frequently also show psychotic symptoms such as delusions, hallucinations, paranoia, or grossly bizarre behavior. These symptoms are generally experienced as discrete episodes of depression and then of mania that last for a few weeks or months, with intervening periods of complete normality. The sequence of depression and mania can vary widely from person to person and within a single individual, with either mood abnormality predominating in duration and intensity. Manic individuals may injure themselves, commit illegal acts, or suffer financial losses because of the poor judgment and risk-taking behavior they display when in the manic state.

There are two types of bipolar disorders. The first, commonly known as bipolar 1, has several variations but is characterized primarily by mania, with or without depression. Its most common form involves recurrent episodes of mania and depression, often separated by relatively asymptomatic periods. The second type of bipolar disorder, typically called bipolar 2 (bipolar II), is characterized primarily by depression accompanied—often right before or right after an episode of depression—by a condition known as hypomania, which is a milder form of mania that is less likely to interfere with routine activities.

The lifetime risk for developing bipolar disorder is about 1 percent and is about the same for men and women. The onset of the illness often occurs at about age 30, and the illness persists over a long period. The predisposition to develop bipolar disorder is partly genetically inherited. Antipsychotic medications are used for the treatment of acute or psychotic mania. Mood-stabilizing agents such as lithium and several antiepileptic medications have proved effective in both treating and preventing recurrent attacks of mania.

Major depressive disorder is characterized by depression without manic symptoms. Episodes of depression in this disorder may or may not be recurrent. In addition, the depression can take on a number of different characteristics in different people, such as catatonic features, which include unusual motor or vocal behavior, or melancholic features, which include profound lack of responsiveness to pleasure. People with major depression are considered to be at high risk of suicide.

Symptoms of major depressive disorder include a sad or hopeless mood, pessimistic thinking, a loss of enjoyment and interest in one’s usual activities and pastimes, reduced energy and vitality, increased fatigue, slowness of thought and action, change of appetite, and disturbed sleep. Depression must be distinguished from the grief and low spirits felt in reaction to the death of a loved one or some other unfortunate circumstance. The most dangerous consequence of severe depression is suicide. Depression is a much more common illness than mania, and there are indeed many sufferers from depression who have never experienced mania.

Major depressive disorder may occur as a single episode, or it may be recurrent. It may also exist with or without melancholia and with or without psychotic features. Melancholia implies the biological symptoms of depression: early-morning waking, daily variations of mood with depression most severe in the morning, loss of appetite and weight, constipation, and loss of interest in love and sex. Melancholia is a particular depressive syndrome that is relatively more responsive to somatic treatments such as antidepressant medications and electroconvulsive therapy (ECT).

It is estimated that women experience depression about twice as often as men. While the incidence of major depression in men increases with age, the peak for women is between ages 35 and 45. There is a serious risk of suicide with the illness; of those who have a severe depressive disorder, about one-sixth eventually kill themselves. Childhood traumas or deprivations, such as the loss of one’s parents while young, can increase a person’s vulnerability to depression later in life, and stressful life events, especially where some type of loss is involved, are, in general, potent precipitating causes. Both psychosocial and biochemical mechanisms can be causative factors in depression. The best-supported hypotheses, however, suggest that the basic cause is faulty regulation of the release of one or more neurotransmitters (e.g., serotonin, dopamine, and norepinephrine), with a deficiency of neurotransmitters resulting in depression and an excess causing mania. The treatment of major depressive episodes usually requires antidepressant medications. Electroconvulsive therapy may also be helpful, as may cognitive, behavioral, and interpersonal psychotherapies.

The characteristic symptoms and patterns of depression differ with age. Depression may appear at any age, but its most common period of onset is in young adulthood. Bipolar disorders also tend to appear first in young adulthood.

Other mood disorders

Less-severe forms of mental disorder include dysthymia, or persistent depressive disorder, a chronically depressed mood accompanied by one or more other symptoms of depression, and cyclothymic disorder (also known as cyclothymia), marked by chronic, yet not severe, mood swings.

Dysthymia may occur on its own but more commonly appears along with other neurotic symptoms such as anxiety, phobia, and hypochondriasis. It includes some, but not all, of the symptoms of depression. Where there are clear external grounds for a person’s unhappiness, a dysthymic disorder is considered to be present when the depressed mood is disproportionately severe or prolonged, when there is a preoccupation with the precipitating situation, when the depression continues even after removal of the provocation, and when it impairs the individual’s ability to cope with the specific stress. Although dysthymia tends to be a milder form of depression, it is nevertheless persistent and distressing to the person experiencing it, especially when it interferes with the person’s ability to conduct normal social or work activities. In cases of cyclothymic disorder, the prevailing mood swings are established in adolescence and continue throughout adult life.

At any time, depressive symptoms may be present in one-sixth of the population. Loss of self-esteem, feelings of helplessness and hopelessness, and loss of cherished possessions are commonly associated with minor depression. Psychotherapy is the treatment of choice for both dysthymic disorder and cyclothymic disorder, although antidepressant medications or mood-stabilizing agents are often beneficial. Symptoms must be present for at least two years in order for a diagnosis of dysthymic or cyclothymic disorder to be made.

Major depressive disorder and dysthymia are much more prevalent than the bipolar disorders and cyclothymic disorder. The former disorders, which feature depressive symptoms exclusively, are also diagnosed more frequently in women than in men, whereas the latter tend to be diagnosed to about the same extent in women and men. Lifetime prevalence of major depression appears to be well over 10 percent for women and 5 percent for men. The prevalence for dysthymia is about 6 percent among the general population in the United States, but it is at least twice as common in women as in men. Lifetime prevalence rates reported for the bipolar disorders and cyclothymic disorder are roughly 1 percent or less.