THIRD EDITION
`
`EDITED BY
`
`ROBERT E. HALES, M.D., M.B.A.
`
`Professor and Chair, Department of Psychiatry,
`University of California, Davis School of Medicine;
`
`Director, Behavioral Health Center, UC Davis Health System;
`Medical Director, Sacramento County Mental Health Services,
`
`Sacramento, 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
`
`American _
`sychlatrlc
`
`Press, Inc.
`
`Washington, DC
`London, England
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`THE AMERICAN PSYCHIATRIC PRESS
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`TEXTBOOK OF PSYCHIATRY
`
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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 accurate as of the time of publication and consistent with standards set by the U.S. Food and Drug Ad-
`ministration 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 sometimes occur, we recommend that readers fol-
`low 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 represent the policies and opinions of the Press or the American Psychiatric Association.
`
`Diagnostic criteria included in this textbook are reprinted, with permission, from the Diagnortic and Statirtical Manual of
`Mental Dirorderr, 4th Edition. Copyright 1994, American Psychiatric Association.
`
`Copyright © 1999 American Psychiatric Press, Inc.
`
`ALL RIGHTS RESERVED
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`Third Edition
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`Library of Congress Cataloging-in-Publication Data
`The American Psychiatric Press textbook of psychiatry / edited by
`Robert E. Hales, Stuart C. Yudofsky, John A. Talbott. — 3rd ed.
`p.
`cm.
`
`Includes bibliographical references and index.
`ISBN 0-88048-819-0 (alk. paper)
`II. Yudofsky, Stuart C.
`1. Psychiatry.
`1. Hales, Robert E.
`III. Talbott, John A.
`IV. Title: Textbook of psychiatry.
`[DNLM:
`1. Mental Disorders.
`2. Psychiatry. WM 100 A5112 1999]
`RC454.A197
`1999
`
`616.89—dc21
`DNLM/DLC
`for Library of Congress
`9
`British Library Cataloguing in Publication Data
`A CIP record is available from the British Library.
`
`_
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`98-43411
`CIP
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`_T.,-,.
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`MOOD DISORDERS
`
`
`CHAPTER 13
`
`STEVEN L. DUBOVSKY, MD.
`RANDALL BUZAN, MD.
`
`One know: not whether there can be human compassionfor anemia ofthe xoul. I/Vhen thepitch oflife 2': dropped and
`the xpirit ix :0put over and reversed that only 1': horrihle which before wassweet and worldly and ofthe day, the hu-
`man relation dixappearx.
`
`—Oliver Onions
`
` ood
`
`relatively '
`be
`can
`disorders
`.. straightforward, or they can assume
`complex forms that can be difficult to treat. In this chap-
`ter, we review the epidemiology, diagnosis, cornorbidity,
`and treatment of the wide variety of affective syndromes
`that are encountered in psychiatric practice.
`
`EPIDEMIOLOGY
`
`Estimates of the incidence and prevalence of mood disor-
`ders vary. In the United States, the lifetime risk of a major
`depressive episode is said to be around 6 % , and the lifetime
`risk of any mood disorder is said to be around 8% (Cassem
`1995; Kashani and Nair 1995). The prevalence of major
`
`depression ranges from 2.6% to 5.5% in men and from
`6.0% to 11.8% in women (Fava and Davidson 1996). The
`prevalence of dysthymia is 3%—4% (Keller et al. 1996).
`Some reports suggest that as much as 48% of the United
`States population has had one or more lifetime mood epi-
`sodes (Cassem 1995). Most studies have found unipolar
`depression in general to be twice as common in women as
`in men (Reynolds et al. 1990). The meaning of the gender
`difference remains to be clarified. Gender does not appear
`to affect the prevalence of bipolar disorder (Reynolds et al.
`1990). The incidence of major depression is higher in sep-
`arated or divorced people than in married individuals, es-
`pecially men, and in medically ill patients (Lehtinen and
`Joukamaa 1994; Reiger et al. 1988), and depression is asso-
`ciated with greater use of general health services
`
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`THE AMERICAN PSYCHIATRIC PRESS TEXTBOOK OF PSYCHIATRY, THIRD EDITION
`480
`
`(VVeissman et al. 1988b). The prevalence ofmaj or depres-
`sion in primary care practice is 4.8%—9.2 %, and the preva-
`lence of all depressive disorders is 9%-—20°/o, which makes
`mood disorders the most common psychiatric problems in
`primary care (McDaniel et al. 1995).
`The effects of culture and stress on the prevalence of
`depression were illustrated by the Cross—National Collab-
`orative Group study of 10 countries, which used the Diag-
`nostic Interview Schedule to make DSM—III (American
`Psychiatric Association 1980) diagnoses (VVeissman et al.
`1996). In this study, the lifetime rate for major depression
`varied from a low of 1.5 cases/ 100 adults in Taiwan to as
`
`many as 19.0/100 in Beirut, and the annual rate of depres-
`sion was as low as 0.8 cases/ 100 in Taiwan and as high as
`5.8/100 in New Zealand.
`
`The prevalence of bipolar disorder is generally re-
`ported as being between 1% and 2.5% (Akiskal 1995b;
`Angst 1995; Bebbington 1995; Kashani and Nair 1995);
`however, some studies suggest rates for bipolar mood dis-
`orders of 3 %—6.5% (Akiskal 1995b; Angst 1995)‘L..The fre-
`quency with which bipolar disorder isdiagnosed probably
`depends on how it is defined; broader definitions produce
`significantly higher rates (Akiskal 1995b; Angst 1995).
`Most prevalence studies require the presence ofmania for a
`bipolar diagnosis to be recorded, but the bipolar II variant,
`which is characterized by episodes of hypomania but not
`mania, is more common than the bipolar I variant (Cassano
`et al. 1989; Simpson et al. 1993). Ifbipolar spectrum disor-
`ders (Akiskal 1995b), or subsyndromal and complex forms
`ofbipolar disorder (discussed later in this chapter), are also
`considered, the incidence of bipolar mood disorder is sub-
`stantially higher. Roughly 10%—-15% of patients with a di-
`agnosis of unipolar depression will eventually receive a re-
`vised diagnosis of bipolar disorder (Olie et al. 1992).
`When conservative criteria are used, between 5% and
`15% of cases of adult depression are found to be bipolar
`(Bebbington 1995; Geller et al. 1996). Akiskal’s group
`(Cassano et al. 1989) found that one-third of patients with
`primary depression met their criteria for bipolar spectrum
`disorders. The risk of bipolarity is higher in juvenile major
`depression—at least 20% in adolescents and 32% in chil-
`dren ages less than 11 years (Geller et al. 1996). The life-
`time rate of bipolar disorder is relatively consistent across
`cultures, ranging from 0.3/100 in Taiwan to 1.5/100 in
`New Zealand (VVeissman et al. 1996).
`In all industrialized countries in the world, the inci-
`dence of depression, mania, suicide, and psychotic mood
`disorders has been increasing in every generation born af-
`ter 1910 (Cross-National Collaborative Group 1992;
`Klerman 1988; Klerman et al. 1985). For unknown rea-
`sons, there was an abrupt jump in the rate of increase for
`
`people born after 1940—a true increase in the incidence of
`mood disorders (cohort effect) and not a function of better
`recognition (Cross-National Collaborative Group 1992;
`Klerman 1988; Klerman et al. 1985). Not only are mood
`disorders becoming more common, but they are appearing
`at an earlier age (especially bipolar mood disorders) (Lasch
`and Weissman 1990).
`Suicide is an obvious public health problem that com-
`plicates mood disorders more frequently than other condi-
`tions. The lifetime risk of suicide in mood disorders is
`
`10%—1 5 % (Barklage 1991; Guze and Robbins 1970;
`Mueller and Leon 1996), and the risk of attempted suicide
`was increased 41-fold in depressed patients compared with
`those with other diagnoses in the Epidemiologic Catch-
`ment Area survey (Petronis et al. 1990). It is well known
`that women attempt suicide more frequently than men, but
`men are more likely to succeed. In one study, however, the
`excess risk of completed suicide in men was entirely ac-
`counted for by a higher prevalence of substance abuse in
`men and a greater likelihood that women have primary re-
`sponsibility for children under age 18 (Young et al. 1994).
`The risk of sujcide=is high in mania as well as in depression.
`Patients with mixed bipolar states characterized by a com-
`bination of depression, rage, and grandiosity may be more
`likely to involve others in a suicide attempt—for example,
`through gunfights with the police. As many as 4% ofpeople
`who commit suicide murder someone else first.
`
`Although many clinicians agree on factors that in-
`crease the risk ofsuicide, formal attempts to predict suicide
`have been disappointing (Oxley and Van Meter 1996). This
`is not surprising; suicide is such a rare event (in the United
`States, the rate is about 11/100,000) that a prohibitively
`large number of patients would have to be followed pro-
`spectively to demonstrate that a constellation of features
`predicted an increased risk. In addition, no consensus exists
`about how long to follow a depressed patient before a con-
`clusion can be made that suicide will not occur. There may
`be a statistically significant association between suicide and
`traditional risk factors such as older age, recent loss, male
`sex, bipolar depression, psychosis, comorbid substance
`abuse, history of a suicide attempt (especially if it was dan-
`gerous), and family history ofsuicide, but this association is
`not necessarily helpful in predicting suicide in an individ-
`ual patient.
`Despite the demonstrated inability of mental health
`professionals to predict (or prevent) suicide in any system-
`atic manner (H. L. Miller et al. 1984), patients, families,
`and courts expect them to be able to do so. In an evaluation
`of immediate suicide risk, factors summarized in Table
`13-1 can be considered (Oxley and Van Meter 1996;
`Pokorny 1993; Young et al. 1994). However, these factors
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`MOOD DISORDERS
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`TABLE I3-1. Factors suggesting an increased risk of
`suicide
`
`Demographic factors
`Male sex
`
`Recent loss
`
`Never married
`
`Older age
`
`Symptoms
`
`Severe depression
`
`Anxiety
`
`Hopelessness
`
`Psychosis, especially with command hallucinations
`
`History
`
`History of suicide attempts, especially if multiple or severe
`attempts
`
`Family history of suicide
`Active substance abuse
`
`Suicidal thinking
`
`Presence of a specific plan
`
`Means available to carry out the plan
`
`Absence of factors that would keep the patient from
`completing the plan
`Rehearsal of the plan
`
`at best suggest increased immediate risk. In addition, it is
`not known whether one risk factor is more important than
`another or how risk factors may interact with each other
`(Oxley and Van Meter 1996). Given the current state of
`knowledge, it is probably impossible for anyone to predict
`with any accuracythe long—term risk ofcompleted suicide.
`
`MOOD DISORDERS IN SPECIAL POPULATIONS
`
`Postpartum depression occurs in about 10% of mothers;
`risk factors include a history ofa mood disorder, unwanted
`pregnancy, unemployment of the mother,
`lack of
`breast—feeding, and the mother as head of the household
`(I. Hopkins et al. 1984; Warner et al. 1996). Postpartum
`depression increases the chance of alcohol and illicit drug
`use in teenage mothers (Barnet et al. 1995). There is some
`evidence that depression in a mother adversely affects tem-
`perament (C. T. Beck 1996) and cognitive development
`(Hay and Kumar 1995) in the infant. D epressed mothers of
`preschoolers have more negative perceptions ofand inter-
`actions with their children (Lang et al. 1996).
`Estimates of the prevalence of major depression in el-
`derly people range from 2 %—4% in community samples to
`12 % of medically hospitalized patients to 16% of geriatric
`patients in long—term care (Blazer and Koenig 1996). Geri-
`
`atric depression is associated with an increased likelihood
`of cerebrovascular disease and enlarged ventricles and may
`be more likelythan depression in younger patients to be ac-
`companied by prominent cognitive complaints (Soares and
`Mann 1997).
`
`Major depressive disorder (MDD) is said to occur in as
`many as 18 % ofpreadolescents, with no gender differences
`(Kashani and Nair 1995). However, mood disorders are of-
`ten underdiagnosed in this population because many clini-
`cians still do not believe that depression occurs in children
`and because depression may be more difficult to recognize
`in children than in older patients. Among adolescents, the
`prevalence ofMDD has been reported to be 4.7% in 14- to
`16—year—olds (Kashani and Nair 1995). By this age, depres-
`sion is more common in girls than in boys (Kashani and
`Nair 1995). In nonclinical samples, up to one—third of ado-
`lescents reported some depressive symptoms (Kashani and
`Nair 1995). Major depression in adolescents is associated
`with substance abuse and antisocial behavior, both ofwhich
`sometimes obscure the affective diagnosis (Kashani and
`Nair 1995). The lifetime prevalence of bipolar disorder
`was 0.6% in 150 adolescents who were not psychiatrically
`referred (Kashani and Nair 1995). As discussed later in this
`chapter, many cases ofbipolar disorder in younger patients
`may be overlooked because many depressed children and
`adolescents have not yet had time to exhibit mania and be-
`cause manic symptoms, when present, may be confused
`with behavior disorders and attention—def1cit disorder.
`
`ECONOMICS OF MOOD DISORDERS
`
`Depression produces more impairment of physical func-
`tioning, role functioning, social functioning, and per-
`ceived current health, is associated with more bodily pain,
`and causes patients to spend more days in bed due to poor
`health than hypertension, diabetes, arthritis, and chronic
`pulmonary disease (VVells et al. 1989). In a study ofgeneral
`medical patients in a health maintenance organization, pa-
`tients with depressed mood or anhedonia of2 weeks’ dura-
`tion but with an insufficient number of additional symp-
`toms to meet full criteria for MDD still had 7.7 times as
`
`much impairment of social, family, and work functioning
`as did patients without any depressive symptoms (Olfson
`1996). The total cost of depressive disorders in the United
`States is generally estimated at $44 billion (Hall and VI/"ise
`1995). This is equivalent to the total cost of coronary heart
`disease, a condition that is no more prevalent and less
`readily treatable than depression. The direct costs of treat-
`ing depression are about $12 billion, only $890 million of
`which is accounted for by the price of antidepressants
`(Hall and Wise 1995). Yet, tremendous effort is being
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`expended by third—party reviewers to get physicians to pre-
`scribe cheaper antidepressants. The morbidity cost of de-
`pressive disorders in the United States is around $24 bil-
`lion, and the mortality costs are $8 billion; these costs can
`be attributed in part to increased accident rates, substance
`abuse, development ofsomatic illness, and increased use of
`medical hospitalization and outpatient treatment (Hall
`and Wise 1995).
`
`for psychosis in use by most clinicians. Alternating depres-
`sion and elation was called qyclot/aymia, which was classified
`with the personality disorders on the grounds that it was
`chronic and was not caused by a specific circumstance. In
`‘ subsequent editions of DSM (discussed later in this chap-
`ter), mood disorder diagnoses are based on symptom clus-
`ters rather than the presence or absence of an identifiable
`precipitant, since the presence ofa precipitant does not de-
`monstrably affect the course or treatment response of
`mood disorders.
`
`DIAGNOSIS
`
`Attempts to classify depression date back to at least the
`fourth century B.C., when Hippocrates coined the terms
`melanc/aolia (black bile), and mania (to be mad). The inde-
`pendent descriptions in 1854- by two French physicians,
`Falret and Baillarger, offolie circulaire and la folie a double
`fiorme were the first formal diagnoses of alternating epi-
`sodes of mania and depression as a single disorder (Sedler
`1983). At the beginning of the current century, Emil
`Kraepelin differentiated schizophrenia (dementia prac-
`cox) from “manic—depressive insanity” on the basis ofa de-
`teriorating course of the former and an episodic course of
`the latter (Akiskal 1996). Kraepelin (1921) believed that
`manic—depressive insanity was a single illness that included
`“periodic and circular insanity,” mania, and melancholia.
`Many of Kraepelin’s observations of the symptoms and
`course of mood disorders remain accurate, but manic-
`depressive (bipolar) disorder is now known to be a complex
`group of disorders that share features such as a high rate of
`recurrence and alternations of mood states but differ in
`
`other important respects.
`In the United States, the first edition ofDSM, Diagnos-
`tic and Statistical Manual: Mental Disorders (American Psy-
`chiatric Association 1952), reflected the influence of
`Adolph Meyer. Meyer believed that psychiatric disorders
`were reactions to conflict or stress that were more specific
`to the individual than to the illness. Psychotic mood disor-
`ders (e.g., psychotic depressive reaction) were diagnosed
`on the basis not of hallucinations and delusions but of se-
`
`verity and lack ofa precipitant (American Psychiatric Asso-
`ciation 1952). In DSM-II (American Psychiatric Associa-
`tion l968), involutional melanc/oolia and manic—depressive
`psychosis were added. The concept of a depressive reaction
`was maintained as depressive neurosis, which was considered
`a neurotic reaction to an internal conflict or external event.
`
`In the absence of a precipitant, a diagnosis ofpsychotic de-
`pressive reaction was made for a single episode and
`manic—depressive psychosis for recurrent depressive epi-
`sodes, whether or not the patient met traditional criteria
`
`ENDOGENOUS AND REACTIVE DEPRESSION
`
`The differentiation of depression according to whether a
`precipitant is present is derived from an early distinction
`between endogenous (vital or melancholic) and reactive
`depression. In its original use by German descriptive psy-
`chiatrists, the term reactive referred to a depressed patient’s
`ability to react positively to interactions and events and
`thus implied the presence of milder symptomatology. As
`the term was translated into English, however, it came to
`mean depression that developed in reaction to some exter-
`nal stress, thus implying an association between mild de-
`pression and depression in response to stress. In DSM-II,
`this concept was conserved as neurotic depressive reaction. In
`later informal diagnostic schemes, milder forms ofdepres-
`sion that are more responsive to the environment evolved
`into the concept of/aysteroid dysp/aoria, which is a type ofde-
`pression with atypical symptoms that occurs in a patient
`with interpersonal sensitivity and a characterological ten-
`dency to dramatize (Shea and Hirschfeld 1996). In
`DSM—III-R (American Psychiatric Association 198 7) and
`DSM-IV (American Psychiatric Association 1994a), the
`term atypical depression (a modifier ofa major depressive ep-
`isode) is more or less equivalent to /aysteroid dysp/aoria and
`the modern derivative of neurotic depression.
`Atypical depression is distinguished by mood reactiv-
`ity (i.e., the capacity to be cheered up temporarily by posi-
`tive interactions or events) as well as by severe fatigue
`(leaden paralysis), sensitivity to rejection, self—pity, a re-
`verse diurnal mood swing (depression is worse later in the
`day), and reverse vegetative symptoms (e.g., increased in-
`stead of decreased appetite and sleep) (M. T Tsuang and
`Faraone 1996). About 15% of depressive episodes have
`atypical features. Atypical symptoms are more common in
`bipolar depression. As is discussed later, atypical depres-
`sion appears to respond better to monoamine oxidase
`inhibitor (MAOI) antidepressants than to other antide-
`pressants.
`In contrast to reactive depression, the term endogenous
`depression referred in the German literature to depression
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`MOOD DISORDERS
`483
`
`that was unresponsive to the environment and in the Amer-
`ican literature to depression with greater severity, more
`considerable guilt and loss of interest, typical vegetative
`symptoms such as decreased appetite and sleep, and other
`physical symptoms such as difficulty concentrating, early
`morning awakening, and a diurnal mood swing (depression
`is worse in the morning) (M. T. Tsuang and Faraone
`1996). In DSM-IV, the melancbolicfizatures specifier retains
`most of the features of endogenous depression; recent re-
`search suggests that “lack of reactivity” and “distinct qual-
`ity of depressed mood” predict the full syndrome most con-
`’ sistently (K. S. Kendler 1997). However, melancholic
`depression can appear in response to an obvious precipi-
`tant. Endogenous depression has a better response to
`tricyclic antidepressants than does reactive depression and
`has a lower rate of response to psychotherapy and placebo
`(M. T. Tsuang and Faraone 1996).
`Recent work has confirmed that the melancholic sub-
`
`type of major depression is a more severe form ofmajor de-
`pression that is associated with more depressive episodes,
`more symptoms, more impairment, more help-seeking,
`and more comorbidity with anxiety disorders and nicotine
`dependence but that is not qualitatively different from
`nonmelancholic major depression (K. S. Kendler 1997). In
`twins, the presence of MDD with melancholic features in
`one twin increased the risk ofmajor depression but notnec-
`essarily melancholia in the other twin (K. S. Kendler
`1997). Twin studies do not suggest an environmental influ-
`ence on liability to melancholia in depressed patients (K. S.
`Kendler 1997). It is also now appreciated that melancholic
`and atypical depression are not necessarily mutually
`exclusive.
`
`DIAGNOSIS AND DSM-IV
`
`The term afifect usually refers to the outward and change-
`able manifestation of a person’s emotional tone, whereas
`mood is a more enduring emotional orientation that colors
`the person’s psychology (American Psychiatric Associa-
`tion 1984a). However, the change from aflective disorders in
`DSM-III to mood disorders in DSM-IV does not imply a
`reconceptualization of what these disorders primarily in-
`volve (i.e., dysregulation of mood or dysregulation of af-
`fect); the two terms are used interchangeablyin DSM-IV.
`DSM-IV distinguishes between mood episodes and
`mood disorders (Fava and Davidson 1996; First et al.
`1996). An episode is a period lasting at least 2 weeks during
`which there are enough symptoms for full criteria to be met
`for the disorder. The criteria for a major depressive episode
`are summarized in Table 13-2. Patients with or without a
`
`history of mania may have a major depressive episode if
`
`TABLE 13-2. DSM-IV criteria for a 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 gen-
`eral medical condition, or mood-incongruent delusions or hal-
`lucinations.
`
`(1) depressed mood most of the day, nearly every day, as
`indicated by either 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.
`
`(3)
`
`(2) markedly diminished interest or pleasure in all, or
`almost all, activities most of the day, nearly every day
`(as indicated by either subjective account or
`observation made by others)
`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.
`insomnia or hypersomnia nearly every day
`(4)
`(5) psychomotor agitation or retardation nearly
`every day (observable by others, not merely
`subjective feelings of restlessness or being slowed
`down)
`
`(6)
`(7)
`
`fatigue or loss of energy nearly every day
`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 subjective
`account or as observed by others)
`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
`
`(9)
`
`The symptoms do not meet criteria for a mixed
`episode.
`The symptoms cause clinically significant distress or
`impairment in social, occupational, or other important
`areas of functioning.
`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).
`The symptoms are not better accounted for by Bereave-
`ment, 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.
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`484
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`THE AMERICAN PSYCHIATRIC PRESS TEXTBOOK OF PSYCHIATRY, THIRD EDITION
`
`they fulfill these criteria, but major depressive disorder
`(MDD) refers to one or more episodes of major depression
`in the absence of mania or hypomania (i.e., unipolar de-
`pression). A major depressive episode may be modified by
`additional specifiers for melancholic features (Table 13-3)
`and/or atypical features (Table 13-4).
`The interpretation of studies of mood disorders is fa-
`cilitated by familiarity with several common terms (Fava
`and Davidson 1996; First et al. 1996). In most treatment
`studies, response is defined as at least 50% improvement,
`whereas partial response is 25%—S 0% improvement and
`nonresponse is < 25% improvement. According to this ter-
`minology, patients who are still half as symptomatic as at
`the beginning of treatment will be considered responders
`at the end of a treatment study. This is not a trivial point,
`given that most studies consider improvement rather than
`remission as the end point. Remission is defined as the state
`of having few or no symptoms of a mood disorder for at
`least 8 weeks. Recovery, the period after remission, is pres-
`ent if no symptoms have been present for more than 8
`weeks, and the term implies that the disorder is quiescent.
`A relapse is a return of symptoms during the period of re-
`mission, and the term implies continuation of the original
`episode; whereas recurrence is a later return of symptoms
`(during recovery), and this term implies development of a
`
`TABKE 13%. DSM-IV melancholic features
`
`specifier
` ::._.?
`
`With melancholic features (can be applied to the current or
`most recent major depressive episode in major depressive dis-
`order and to a major depressive episode in bipolarl 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)
`
`(6)
`
`significant anorexia or weight loss
`
`excessive or inappropriate guilt
`
`_:__
`
`TABLE 13-4. DSM-IV atypical features specifier
`__é.
`
`With atypical features (can be applied when these features
`predominate during the most recent 2 weeks of a major de—
`pressive episode in major depressive disorder or in bipolar I or
`bipolar II disorder when the major depressive episode is the
`most recent type of mood episode, or when these features pre-
`dominate during the most recent 2 years of dysthymic disor-
`der)
`
`A. Mood reactivity (i.e., mood brightens in response to
`actual or potential positive events)
`
`B. Two (or more) of the following features:
`(1)
`significant weight gain or increase in appetite
`
`(4)
`
`(2) hypersomnia
`(3)
`leaden paralysis (i.e., heavy, leaden feelings in arms
`or legs)
`long-standing pattern of interpersonal rejection
`sensitivity (not limited to episodes of mood
`disturbance) that results in significant social or
`occupational impairment
`C. Criteria are not met for with melancholic features or
`with catatonic features during the same episode.
`
`
`new episode. These distinctions can be difficult to make in
`clinical practice. For example, mild residual symptoms of
`an initial episode may be overlooked or may be attributed
`to character pathology after improvement ofthe more dra-
`matic manifestations of an episode; this may lead to the
`conclusion that a return of more severe symptoms repre-
`sents a new episode rather than an exacerbation ofthe orig-
`inal episode.
`
`UNIPOLAR AND BIPOLAR I\/IOOD DISORDERS
`
`One ofthe most important distinctions between mood dis-
`orders is the distinction between unipolar and bipolar cat-
`egories (Leonhard 1987a, 1987b). Unipolar mood disor-
`ders are characterized by depressive symptoms in the
`absence of a history of a pathologically elevated mood. In
`bipolar mood disorders, depression alternates or is mixed
`with mania or hypomania. Patients who have only had re-
`current mania (“unipolar mania”) are given the diagnosis
`of bipolar mood disorder on the assumption that they will
`eventually develop an episode of depression (M. T. Tsuang
`and Faraone 1996). DSM-IV criteria for a manic episode
`are summarized in Table 13-5 . Hypomania, a milder form
`of pathologically elevated mood that can be present for a
`shorter period before it is diagnosed, is described in Table
`13-6. Although most people think of elation as a defining
`characteristic of mania and hypomania, many patients ex-
`perience only irritability, anxiety, or a dysphoric sense of
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`MOOD DISORDERS
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`TABLE 135. DSM-IV criteria for a manic episode
`
`A. A distinct period of abnormally and persistently elevated,
`expansive, or irritable mood, lasting at least 1 week (or
`any duration if hospitalization is necessary).
`
`B. During the period of mood disturbance, three (or more)
`of the following symptoms have persisted (four if the
`mood is only irritable) and have been present to a
`significant degree:
`
`(1)
`
`inflated self—esteem or grandiosity
`
`(2) decreased need for sleep (e.g., feels rested after only
`3 hours of sleep)
`
`(3) more talkative than usual or pressure to keep talking
`
`(4)
`
`flight of ideas or subjective experience that thoughts
`are racing
`
`(5) distractibility (i.e., attention too easily drawn to
`unimportant or irrelevant external stimuli)
`
`(6)
`
`(7)
`
`increase in goal—directed activity (either socially, at
`work or school, or sexually) or psychomotor
`agitation
`
`excessive involvement in pleasurable activities that
`have a high potential for painful consequences (e.g.,
`engaging in unrestrained buying sprees, sexual in-
`discretions, or foolish business investments)
`
`C. The symptoms do not meet criteria for a mixed episode.
`F3 The mood disturbance is sufficiently severe to cause
`marked impairment in occupational functioning or in
`usual social activities or relationships with others, or to
`necessitate hospitalization to prevent harm to self or
`others, or there are psychotic features.
`
`E. The symptoms are not due to the direct physiological
`effects of a substance (e.g., a drug of abuse, a medication,
`or other treatment) or a general medical condition (e.g.,
`hyperthyroidism).
`
`increased energy, as if they were