The ~merican Psychiatric Press
`Textbook of Psychiatry
`Second Edition
`
`Edited by
`
`Robert E. Hales, M.D.
`Chairman, Department of Psychiatry,
`California Pacific Medical Center;
`Clinical Professor of Psychiatry,
`University of California, San Francisco;
`San Francisco, California
`
`Stuart C. Yudofsky, M.D.
`D. C. and Irene Ellwood Professor and Chairman,
`Department of Psychiatry and Behavioral Sciences,
`Baylor College of Medicine;
`Chief, Psychiatry Service,
`The Methodist Hospital,
`Houston, Texas
`
`John A. Talbott, M.D.
`Professor and Chairman,
`Department of Psychiatry,
`University of Maryland School of Medicine,
`Baltimore, Maryland
`
`Washington, DC
`
`American
`B~)'chiatric ,
`Press, Inc
`
`London, England
`
`1 of 32
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`Note: The authors have worked to ensure that all information in this book
`concerning drug dosages, schedules, and routes of administration is accu(cid:173)
`rate as of the time of publication and consistent with standards set by the
`U.S. Food and Drug Administration and the general medical community. As
`medical research and practice advance, however, therapeutic standards may
`change. For this reason and because human and mechanical errors some(cid:173)
`times occur, we recommend that readers follow the advice of a physician
`who is directly involved in their care or in the care of a member of their
`family.
`
`Books published by the American Psychiatric Press, Inc., represent the
`views and opinions of the individual authors and do not necessarily repre(cid:173)
`sent the policies and opinions of the Press or the American Psychiatric Asso(cid:173)
`ciation.
`
`Diagnostic criteria included in this textbook are reprinted, with permission,
`from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.
`Copyright 1994, American Psychiatric Association.
`
`Copyright © 1994 American Psychiatric Press, Inc.
`ALL RIGHTS RESERVED
`Manufactured in the United States of America on acid-free paper
`Second Edition 97 96 95 94
`4 3 2 1
`American Psychiatric Press, Inc.
`1400 K Street, N.W., Washingto~, DC 20005
`
`Library of Congress Cataloging-in-Publication Data
`
`American Psychiatric Press textbook of psychiatry I edited by Robert E.
`Hales, Stuart C. Yudofsky, and John A. Talbott. - 2nd ed.
`p. cm.
`Includes bibliographical references and index.
`ISBN 0-88048-388-1
`1. Psychiatry. I. Hales, Robert E. II. Yudofsky, Stuart C.
`III. Talbott, John A.
`[DNLM: 1. Mental Disorders. 2. Psychiatry. WM 100 A51121994]
`RC454.A419 1994
`616.89-dc20
`DNLM/DLC
`for Library of Congress
`
`93-48305
`CIP
`
`British Library Cataloguing in Publication Data
`
`A CIP record is available from the British Library.
`
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`Mood Disorders
`
`James W. Jefferson, M.D.
`John H. Greist, M.D.
`
`The terms 11 mania" and /1 melancholia," which arose
`in antiquity and took on varied meanings over the
`centuries, came into clearer definition in the last
`100 years and continue to be refined. According
`to Berrios (1988), "Historical analysis shows that
`before the nineteenth century these noble words
`were but semantic palimpsests in which meanings
`had been deposited in a staccato fashion" (p. 13).
`Nonetheless, in about 150 A.D., Aretaeus seemed on
`target: "The melancholic cases tend towards de(cid:173)
`pression and anxiety . only ... if, however, respite
`from this condition of anxiety occurs, gaiety
`and hilarity in the majority of cases follows, and
`this finally ends in mania" ( qtd. in Goodwin and
`Jamison 1990, p. 58).
`Originally, mania was a rather nonspecific term
`for madness, and melancholia was a subtype of
`mania associated with a reduction in behavioral
`output. During the 19th century, the current mean(cid:173)
`ing of these terms took shape. As Berrios (1988)
`notes, "In 1800 mania meant / madness' and was the
`best example of total insanity; in 1900 the term
`named a specific psychiatric syndrome" (p. 16). In
`the early 19th century, melancholia attained greater
`specificity by reflecting a sad affect. Photographer
`Hugh W. Diamond in 1858 captured the melan(cid:173)
`choly mood (Figure 13-1; Gilman 1976). By the
`mid-19th century the word /1 depression" had be(cid:173)
`come better established as describing conditions as(cid:173)
`sociated with low mood. Soon, depression and
`melancholia were used interchangeably, and even(cid:173)
`tually melancholia came to represent a severe, en(cid:173)
`dogenous subtype of depression.
`In 1854, Falret described Jolie circulaire, and, in
`the same year, Baillarger, another Fr.ench physician,
`characterized la Jolie a double form-both individuals
`
`independently recognizing alternating episodes of
`mania and depression as a single disorder. Falret
`explained: "We call it circular insanity (la Jolie cir(cid:173)
`culaire) because the unfortunate patients afflicted
`with this illness live out their lives in a perpetual
`circle of depression and manic excitement inter(cid:173)
`rupted by a period of lucidity, which is typically
`brief but occasionally long lasting" (Falret 1854,
`qtd. in Sedler 1983, p. 1129).
`Emil Kraepelin differentiated the episodic
`course and better prognosis of manic-depressive in(cid:173)
`sanity from the chronicity and deterioration of de(cid:173)
`mentia praecox (i.e., schizophrenia). In the late 1800s
`and early 1900s, he expressed the conviction that
`manic-depressive insanity was /1 a single morbid
`process" that included /1 on the one hand the whole
`domain of so-called periodic and circular insanity,
`on the other hand simple mania, the greater part
`of the morbid states termed melancholia and also
`a not inconsiderable number of cases of amentia"
`(Kraepelin 1921, p. 1).
`In the United States, the first edition of the Diag(cid:173)
`nostic and Statistical Manual of Mental Disorders
`(DSM-I) appeared in 1952 and reflected the psycho(cid:173)
`biological influence of Adolph Meyer. Mood dis(cid:173)
`orders that were considered psychotic included
`"involutional psychotic reaction" and /1 affective
`reactions" (i.e., manic-depressive reaction, manic
`type, depressive type, and other; and psychotic
`depressive reaction). Also described were a psy(cid:173)
`choneurotic depressive reaction and cyclothymic
`personality disturbance (American Psychiatric As(cid:173)
`sociation 1952).
`In 1968, DSM-II eliminated the term "reaction"
`and under the heading of major affective disorders
`(affective psychoses) included involutional melan-
`
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`THE AMERICAN PSYCHIATRIC PRESS TEXTBOOK OF PSYCHIATRY
`
`cholia and the manic, depressed and circular types
`of manic-depressive illness (manic-depressive psy(cid:173)
`chosis) (American Psychiatric Association 1968).
`It is important to realize that in both DSM-I and
`DSM-II, an illness characterized exclusively by re(cid:173)
`current depressive episodes was, nonetheless, diag(cid:173)
`nosed as manic-depressive. In DSM-II, depressive
`neurosis was defined as an excessive depressive re(cid:173)
`action to an internal conflict or an external event.
`Cyclothymia, characterized by "recurring and al(cid:173)
`ternating periods of depression and elation," re(cid:173)
`mained classified as a personality disorder.
`Twelve years later, in 1980, DSM-III (American
`Psychiatric Association 1980) incorporated Leon(cid:173)
`hard's concept of monopolar (unipolar) and bipolar
`disorders and thus divided the major affective dis(cid:173)
`orders into bipolar (mixed, manic, and depressed)
`and major depression (single episode and recur(cid:173)
`rent). The /1 other specific affective disorders" cate(cid:173)
`gory included cyclothymic disorder (no longer
`classified as a personality disorder) and dysthymic
`
`I 1
`
`I:
`I
`
`Figure 13-1. Melancholia. Reprinted from Gilman SL
`(ed): The Faces of Madness: Hugh W. Diamond and the
`Origins of Psychiatric Photography. New York, Brunner/
`Mazel, 1976. Copyright 1976, Royal Society of Medicine.
`Used with permission.
`
`disorder (previously known as depressive neuro(cid:173)
`sis). The residual categories of atypical bipolar dis(cid:173)
`order and atypical depression were created to
`include those disorders for which the above catego(cid:173)
`ries were not applicable.
`Only 7 years later the revision of DSM-III ap(cid:173)
`peared (DSM-III-R; American Psychiatric Associa(cid:173)
`tion 1987). In DSM-III-R the affective disorders of
`DSM-III were now referred to as mood disorders.
`Mood was described as "a prolonged emotion that
`colors the whole psychic state" (American Psychiat(cid:173)
`ric Association 1987, p. 213). Affect had been de(cid:173)
`fined elsewhere as /1 the outward manifestation of
`a person's feeling, tone, or mood" (American Psy(cid:173)
`chiatric Association 1984, p. 3). Semantics aside,
`mood disorders and affective disorders are one and
`the same, and, practically speaking, the terms are
`used interchangeably. The diagnostic category of bi(cid:173)
`polar disorder now includes bipolar disorder,
`mixed, manic, or depressed; cyclothymia; and bipo(cid:173)
`lar disorder not otherwise specified (NOS). The de(cid:173)
`pressive disorders include major depression, single
`episode and recurrent; dysthymia (still alternately
`labeled "depressive neurosis" in deference to psycho(cid:173)
`analysts); and depressive disorder NOS. The mood
`disorders were further categorized according to se(cid:173)
`verity, presence or absence of psychotic features,
`and seasonal pattern, and major depression was further
`classified by the presence or absence of melancholia.
`The year 1994 has brought further diagnostic
`sophistication with the introduction of DSM-IV
`(American Psychiatric Association 1994). DSM-IV
`still refers to mood disorders, with some modifica(cid:173)
`tions from DSM-III-R (Table 13-1). Major depres(cid:173)
`sion is now known as major depressive disorder.
`Dysthymia has become dysthymic disorder, and its
`alternative appellation, /1 depressive neurosis," has
`finally been put to rest. Depressive disorder NO?
`has incorporated conditions such as premenstrual
`dysphoria disorder, minor depressive disorder,
`and recurrent brief depressive disorder, all of
`which failed to achieve separate categoryhood,
`and postpsychotic depression of schizophrenia.
`In DSM-IV the bipolar disorders have been
`further refined to remove bipolar II disorder (i.e.,
`recurrent major depressive episodes with hypoma(cid:173)
`nia) from the bipolar disorder NOS residual cate(cid:173)
`gory and give it individual status.
`Three new diagnostic categories have been es(cid:173)
`tablished under mood disorders: mood disorder due
`to a general medical condition, substance-induced
`mood disorder, and mood disorder NOS. The first
`two are transfers from the organic mental disorders
`section in DSM-III-R, and the last may have been
`
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`created for more ambivalent diagnosticians.
`Finally, that apparently large group of patients
`seen most commonly in primary care with a mix(cid:173)
`ture of anxiety and depressive symptoms that does
`not meet diagnostic criteria for a mood disorder are
`addressed in DSM-IV in the category anxiety dis(cid:173)
`orders NOS. The diagnostic and treatment im(cid:173)
`plications of this decision remain to be determined
`(Liebowitz et al. 1990).
`
`while minimizing or denying the mood and cogni(cid:173)
`tive components. Studies have found that over 50%
`of clinically important depression goes unrec(cid:173)
`ognized in primary care. Diagnosis is further
`complicated in the presence of medical illnesses
`and medication side effects that may produce
`"pseudodepressive" manifestations (e.g., insomnia
`secondary to pain, weight loss from malignancy,
`lethargy caused by medication).
`
`• DEPRESSION: GENERAL
`CHARACTERISTICS
`
`In this condition self-reliance is absolutely gone,
`extreme modesty is common or even habitual, a
`featherweight will crush one to the dust, and
`even greatest good fortune will fail to cheer.
`Alexander Haig (1900)
`
`Depression is a term with meanings ranging from
`the transient dips in mood that are characteristic of
`life itself, to a clinical syndrome of substantial se(cid:173)
`verity, duration, and associated signs and symp(cid:173)
`toms that is markedly different from normal. Grief,
`or bereavement, encompasses features of a depres(cid:173)
`sive syndrome but is usually less pervasive and
`more limited in duration.
`The clinical features of depression fall into four
`broad categories:
`
`1. Mood (affect): sad, blue, depressed, unhappy,
`down-in-the-dumps, empty, worried, irritable.
`2. Cognition: loss of interest, difficulty concen(cid:173)
`trating, low self-esteem, negative thoughts,
`indecisiveness, guilt, suicidal ideation, halluci(cid:173)
`nations, delusions.
`3. Behavior: psychomotor retardation or agita(cid:173)
`tion, crying, social withdrawal, dependency,
`suicide.
`4. Somatic (physical): sleep disturbance (insom(cid:173)
`nia or hypersomnia), fatigue, decreased or in(cid:173)
`creased appetite, weight loss or gain, pain,
`gastrointestinal upset, decreased libido.
`
`These findings are reflected in the DSM-IV criteria
`for depressive disorders (given later in this chapter).
`
`D Recognition
`When many of the above-mentioned symptoms are
`prominent, depression is easily recognized. This is
`not always the case, however, because patients may
`present with prominent somatic manifestations
`
`o Impact
`
`Mortality
`
`Depression is a potentially lethal disorder: about
`15% of individuals with a primary affective disor(cid:173)
`der eventually kill themselves. Approximately 50%
`of persons who commit suicide have a primary di(cid:173)
`agnosis of depression (Barklage 1991). Factors asso(cid:173)
`ciated with an early (defined as within 1 year of
`
`Table 13-1. Mood.disorders (DSM-IV)
`
`,
`Depressive disorders
`Major depressive disorder
`Single episode
`Recurrent
`Dysthymic disorder
`Depressive disorder not otherwise specified (NOS)
`Examples:
`Minor depressive disorder
`Recurrent brief depressive disorder
`Postpsychotic depression of schizophrenia
`Bipolar disorders
`Bipolar I disorder
`Single manic episode
`Most recent episode hypomanic
`Most recent episode manic
`Most recent episode mixed
`Most recent episode depressed .
`Most recent episode unspecified
`Bipolar II disorder (recurrent major depressive
`episodes with hypomania)
`Cyclothymic disorder
`Bipolar disorder not otherwise specified (NOS)
`Examples:
`Recurrent hypomania without depression
`Manic episode superimposed on
`delusional disorder
`Mood disorder due to a general medical condition
`Substance-induced mood di~order
`Mood disorder not otherwise specified (NOS)
`
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`
`interview) increased suicide risk in depressed pa(cid:173)
`tients include panic attacks, psychic anxiety, severe
`loss of interest and pleasure (i.e., anhedonia), diffi(cid:173)
`culty concentrating, substance abuse, and marked
`insomnia (Fawcett et al. 1990). Long-term risk
`factors (i.e., 1 to 5 years after interview) include
`hopelessness, suicidal ideation, and prior suicide
`attempts. Needless to say, all depressed individuals
`must be carefully assessed for suicidality, .both ini(cid:173)
`tially and during treatment.
`There is also evidence that comorbid depres(cid:173)
`sion increases the likelihood of death from other
`medical illnesses such as cardiovascular disease
`and cancer.
`
`Morbidity
`
`According to the Medical Outcome Study, depres(cid:173)
`sion had a greater adverse impact on individuals
`than did other chronic conditions such as hyper(cid:173)
`tension, diabetes, arthritis, and lung disease, as
`measured across the dimensions of physical func(cid:173)
`tioning, role functioning, social functioning, num(cid:173)
`ber of days in bed due to poor health, perceived
`current health, and bodily pain (Wells et al. 1989).
`
`Financial
`
`The economic impact of depression includes the
`costs of treatment (i.e., direct costs) and the costs of
`lost productivity due to illness or death (i.e., indi(cid:173)
`rect costs). Based on economic data from 1980, the
`annual financial cost of depression in the United
`States was estimated to be $16.3 billion (Stoudemire
`et al. 1986). More recently, the estimate has grown
`to $43.7 billion ($12.4 billion in direct costs, $7.5 bil(cid:173)
`lion in mortality costs, and $23.8 billion in morbid(cid:173)
`ity costs) (Greenberg et al. 1993).
`
`• MAJOR DEPRESSIVE
`EPISODE
`
`D Diagnosis
`Major depressive episodes occur in both major
`depression and bipolar disorder. They are sub(cid:173)
`classified according to severity (mild, moderate, se(cid:173)
`vere without psychotic features or with psychotic
`features). The DSM-IV diagnostic criteria for a
`major depressive episode are listed in Table 13-2.
`It should be apparent from the criteria that a
`wide variety of clinical presentations will fall under
`
`the umbrella of major depressive episodes. For ex(cid:173)
`ample, the following hypothetical patients are clin(cid:173)
`ically quite different yet diagnostically the same:
`
`Patient A
`Depressed mood
`Insomnia
`Appetite loss
`Difficulty concentrating
`Psychomotor agitation
`
`Patient B
`Loss of pleasure
`Hypersomnia
`Weight gain
`Fatigue
`Psychomotor
`retardation
`
`DSM-IV applies the term "with atypical fea(cid:173)
`tures" to major depressive episodes that have mood
`reactivity (temporary mood improvement in re(cid:173)
`sponse to positive events) and at least two of the
`following for at least 2 weeks:
`
`1. Significant weight gain or increase in appetite
`2. Hypersomnia
`3. Leaden paralysis (i.e., heavy, leaden feelings in
`arms or legs)
`4. Long-standing pattern of interpersonal rejec(cid:173)
`tion sensitivity (not limited to episodes of
`mood disturbance) resulting in significant so(cid:173)
`cial or occupational impairment
`
`D Psychotic Depression
`Psychotic depression is characterized by the pres(cid:173)
`ence of delusions and/ or hallucinations that are
`usually mood-congruent. In other words, these fea(cid:173)
`tures are consistent with the theme of depression
`(death, poverty, nihilism, disease, etc.). Although
`less common, mood-incongruent psychotic features
`may also occur (e.g., thought insertion, thought
`broadcasting, delusions of control).
`There is evidence that psychotic depression, in
`addition to being a severe depression, is also a dis(cid:173)
`tinct syndrome rather than merely the extreme end
`of the severity continuum (Table 13-3; Schatzberg
`and Rothschild 1992).
`
`D Melancholia
`A major depressive episode· with melancholic fea(cid:173)
`tures is characterized in DSM-IV as shown in Table
`13-4. A melancholic tone is conveyed by none other
`than Abraham Lincoln (qtd. in Grinker 1979, p. 6):
`
`I am now the most miserable man living. If what I feel
`were equally distributed to the whole human family,
`there would not be one cheerful face on earth. Whether I
`shall ever be better, I cannot tell; I awfully forebode I shall
`
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`Mood Disorders
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`469
`
`not. To remain as I am is impossible. I must die or be bet(cid:173)
`ter, it appears to me.
`
`Melancholic depression can occur in both major de(cid:173)
`pression and bipolar disorder.
`
`D SeasonalPattern
`Some mood disorders follow a regular seasonal
`pattern, with onset and remission of episodes usu(cid:173)
`ally occurring rather predictably at a particular
`time of year. The DSM-III-R criteria for seasonal
`pattern were criticized as being too narrow ( espe(cid:173)
`cially the 60-day "window") (Faedda et al. 1993),
`and in DSM-IV the definition has been made less
`stringent (Table 13-5).
`Seasonal pattern mood disorders are often re(cid:173)
`ferred to as seasonal affective disorders (SADs),
`a common form of which is "winter" depression
`
`(late fall/ winter onset) that is often linked to
`spring/ summer hypomania. The depression in
`SAD is often charac;terized by hypersomnia, carbo(cid:173)
`hydrate craving, overeating, weight gain, and fa(cid:173)
`tigue, although there are many exceptions to this
`profile (Blehar and Lewy 1990). Also described has
`been a spring/ summer depressive pattern with or
`without fall/ winter mania or hypomania (Faedda
`et al. 1993). While winter depression responds to
`conventional antidepressant drug therapy, research
`has shown that it also responds well to bright arti(cid:173)
`ficial light (see treatment section below).
`
`D Postpartum Mood Disturbance
`While DSM-III-R only mentions that "childbirth
`sometimes precipitates a major depressive episode"
`(American Psychiatric Association 1987, p. 221),
`DSM-IV has included "with postpartum onset" as
`
`Table 13-2. DSM-IV diagnostic criteria for major depressive episode
`
`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. Note: Do
`not include symptoms that are clearly due to a
`general medical condition or mood-incongruent
`delusions or hallucinations.
`1. Depressed mood most of the day, nearly
`every day, as indicated either by subjective
`report (e.g., feels sad or empty) or observation
`made by others (e.g., appears tearful). Note:
`In children and adolescents, can be irritable
`mood.
`2. Markedly diminished interest or pleasure
`in all, or almost all, activities most of the
`day, nearly every day (as indicated either
`by subjective account or observation
`made by others).
`3. 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 gains.
`4. Insomnia or hypersomnia nearly every day.
`5. Psychomotor agitation or retardation nearly
`every day (observable by others, not merely
`subjective feelings of restlessness or being
`slowed down).
`
`6. Fatigue or loss of energy nearly every day.
`7. Feelings of worthlessness or excessive or
`inappropriate guilt (which may be delusional)
`nearly every day (not merely self-reproach or
`guilt about being sick).
`8. Diminished ability to think or concentrate,
`or indecisiveness, nearly every day (either
`by subjective account or as observed by
`others).
`9. 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 do not meet criteria for a mixed
`episode.
`C. The symptoms cause clinically significant distress
`or impairment in social, occupational, or other
`important areas of functioning.
`D. The symptoms are not due to the direct·
`physiological effects of a substance (e.g., a drug
`of abuse, a medication) or a general medical
`condition (e.g., hypothyroidism).
`E. The symptoms are not better accounted for by
`bereavement, i.e., after the loss of a loved one, the
`symptoms persist for longer than 2 months or are
`characterized by marked functional impairment,
`morbid preoccupation with worthlessness, suicidal
`ideation, psychotic symptoms, or psychomotor
`retardation.
`
`I
`
`)'
`i
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`
`Table 13-3. Features that may distinguish psychotic
`(delusional) major depression from
`nonpsychotic major depression
`
`Clinical features: Delusions and/ or hallucinations,
`greater psychomotor agitation or retardation, greater
`guilt.
`Biological findings: Greater hypothalamic-pituitary(cid:173)
`adrenal axis activity, greater dopaminergic activity,
`higher serum dopamine beta-hydroxylase activity,
`greater ventricular-to-brain ratio (CT scan), reduced
`REM sleep, higher CSF HV A/ 5-HIAA ratio.
`Family studies: Higher prevalence of bipolar disorder,
`poorer short-term outcome, greater likelihood of
`becoming bipolar (younger patients).
`Treatment: Poorer placebo response, poorer response
`to antidepressant monotherapy (exception: amoxapine).
`
`Note. CT = computed tomography; CSF = cerebrospinal
`fluid; HV A = homovanillic acid; 5-HIAA = 5-hydroxy(cid:173)
`indoleacetic acid.
`
`a course specifier that can be applied to either
`manic or major depressive episodes in bipolar
`disorder, major depressive disorder, or brief psy(cid:173)
`chotic disorder. In addition to first-onset mood
`syndromes ranging from postpartum blues to post(cid:173)
`partum psychosis (usually affective in nature),
`there is an increased risk of recurrence of preexist(cid:173)
`ing mood disorders in the immediate postpartum
`period (Hopkins et al. 1984).
`
`• MAJOR DEPRESSIVE DISORDER
`
`D Diagnosis
`Major depressive disorder is identified by the
`presence of one or more major depressive episodes
`(see above) in the absence of a history of mania or
`hypomania.
`
`D Epidemiology
`Major depressive disorder is one of the more com(cid:173)
`mon psychiatric disorders: the National Institute of
`Mental Health (NIMH) Epidemiologic Catchment
`Area (ECA) study, based on a survey of over 18,000
`adults in five United States communities, found a
`1-month prevalence of 1.6% and a lifetime preva(cid:173)
`lence of 4.4% (Weissman et al. 1988a, 1988b). The
`mean age at onset was 27 years, with little difference
`according to sex. Studies have shown that individ-
`
`uals born in recent decades appear to have both an
`earlier age at onset and an increased rate of depres(cid:173)
`sion. The reasons for this birth cohort effect are not
`known (Cross-National Collaborative Group 1992).
`The greater recognition of major depressive disor(cid:173)
`der in children and adolescents reflects not only the
`earlier age at onset but also greater acceptance that
`the disorder occurs in these age groups. In general,
`adult diagnostic criteria can be reliably applied to
`children and adolescents. Because bipolar disorder
`often begins during adolescence, an illness that be(cid:173)
`gins with a major depressive episode may remain
`diagnostically ambiguous until one or more further
`mood episodes occur. The prevalence of depression
`in women is uniformly higher than in meri, with
`most studies finding major depression to be twice
`as common (Weissman et al. 1988b).
`
`D Clinical Course
`According to DSM-IV, an episode of major depres(cid:173)
`sive disorder must have a minimum duration of
`2 weeks; an average untreated episode, however,
`lasts 6 or more months. The onset and termination
`of a major depressive episode may be gradual or
`
`Table 13-4. DSM-IV diagnostic criteria for
`melancholic features specifier
`
`Specify if: With melancholic features (can be applied
`to the current or most recent major depressive episode
`in major depressive disorder and to a major depressive
`episode in bipolar I or bipolar II disorder only if it is
`the most recent type of mood episode):
`A. Either of the following, occurring during the most
`severe period of the current episode:
`1. Loss of pleasure in all, or almost all, activities
`2. Lack of reactivity to usually pleasurable stimuli
`(does not feel much better, even temporarily,
`when something good happens)
`B. Three (or more) of the following:
`1. Distinct quality of depressed mood (i.e., the
`depressed mood is experienced as distinctly
`different from the kind of feeling experienced
`after the death of a loved one)
`2. Depression regularly worse in the
`morning
`3. Early morning awakening (at least 2 hours
`before usual time of awakening)
`4. Marked psychomotor retardation or agitation
`5. Significant anorexia or weight loss
`6. Excessive or inappropriate guilt
`
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`Mood Disorders
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`471
`
`abrupt. Although return to the premorbid state ei(cid:173)
`ther spontaneously or with treatment is the rule, a
`chronic outcome is not rare. Keller et al. (1984)
`found that 21 % of 97 patients studied had not re(cid:173)
`covered after 2 years and that most had the per(cid:173)
`sistence of severe depressive symptoms (major
`depressive disorder without full interepisode re(cid:173)
`covery according to DSM-IV). Those subjects
`whose chronic symptoms were less severe were
`considered to be in partial remission, Subsequently,
`with sample size expanded to 431, it was noted at
`5-year follow-up that although 50% had recovered
`within 6 months, 12% were still ill at 5 years (treat(cid:173)
`ments were often less than optimal) (Keller et al.
`1992). Risk factors for chronicity included long du(cid:173)
`ration of illness prior to evaluation, history of
`alcoholism and other nonaffective psychiatric dis(cid:173)
`orders, and low family income.
`Major depressive disorder is usually a recur(cid:173)
`rent disorder. The likelihood of a single episode is
`well under 50%, and once recurrence is established,
`the risk of further episodes increases with subse-
`
`Table 13-5. DSM-IV diagnostic criteria for seasonal
`pattern specifier
`
`A. There has been a regular temporal relationship
`between the onset of major depressive episodes
`in bipolar I or bipolar II disorder or major
`depressive disorder, recurrent, and a particular
`time of the year (e.g., regular appearance of
`the major depressive episode in the fall or
`winter). Note: Do not include cases in which
`there is an obvious effect of seasonal-related
`psychosocial stressors (e.g., regularly being
`unemployed every winter).
`B. Full remissions (or a change from depression to
`mania or hypomania) also occur at a characteristic
`time of the year (e.g., depression disappears in the
`spring).
`In the last 2 years, two major depressive
`episodes have occurred that demonstrate the
`temporal seasonal relationships defined in
`criteria A and B, and no nonseasonal major
`depressive episodes have occurred during
`that same period.
`D. Seasonal major depressive episodes (as described
`above) substantially outnumber the nonseasonal
`major depressive episodes that may have occurred
`over the individual's lifetime. ·
`
`C.
`
`Note. This designation can be applied to the pattern of
`major depressive episodes in bipolar I disorder, bipolar
`II disorder, or major depressive disorder, recurrent.
`
`quent episodes (Thase 1990). The pattern of recur(cid:173)
`rence is variable and generally unpredictable.
`Months, and even years, may separate episodes.
`
`D Comorbidity
`Major depressive disorder commonly coexists with
`other psychiatric conditions. Patients with dysthy(cid:173)
`mic disorder usually have superimposed episodes
`of major depression (so-called double depression).
`Markowitz et al. (1992) found a 68% lifetime preva(cid:173)
`lence of major depression among their dysthymic
`patients. In the ECA study a 27% lifetime preva(cid:173)
`lence of alcohol and other substance abuse was
`found in patients with major depression (Regier et
`al. 1990b ). Anxiety disorders also coexist with
`major depressive disorder. A person with a major
`depressive episode was estimated to be at a 9 to 19
`times increased risk of having an anxiety disorder
`(Regier et al. 1990a).
`Comorbidity does not imply causality, and
`whether major depressive disorder and another
`condition coexist as entirely separate entities or are
`products of a common diathesis, or whether one is
`caused by the other, remains to be determined.
`What is clear is that comorbidity confounds diag(cid:173)
`nosis and influences outcome adversely.
`
`D Etiology
`The causes of major depressive disorder and bipo(cid:173)
`lar disorder are unknown, and a thoroughly satisfy(cid:173)
`ing explanation for the effectiveness of treatments
`is lacking. Elegant efforts have been made to inte(cid:173)
`grate various perspectives into cohesive wholes to
`add substanc.e to the statement that "each individ(cid:173)
`ual has a pattern of genetic, developmental, envi(cid:173)
`ronmental, social, personality, and physiological
`factors that combine to permit or protect against de(cid:173)
`pression at any point in time" (Greist and Jefferson
`1992, p. 8). While theories abound, scientific sup(cid:173)
`port that might convert theory to fact is evolving
`more slowly.
`
`Biological Models
`
`Genetics. Twin, adoption, and family studies
`have established a genetic predisposition toward
`major depressive disorder and bipolar disorder
`(Gershon 1990). There is a higher concordance for
`major mood disorders in identical (i.e., monozy(cid:173)
`gotic) than in fraternal (i.e., dizygotic) twins. Con(cid:173)
`cordance in monozygotic twinships is greater for
`
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`472
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`THE AMERICAN PSYCHIATRIC PRESS TEXTBOOK OF PSYCHIATRY
`
`bipolar disorder than for major depressive dis(cid:173)
`order, suggesting a stronger genetic basis for bipo(cid:173)
`lar disorder. According to the Danish twin study,
`the bipolar probands had a monozygotic con(cid:173)
`cordance