5.1 Depressive Disorders & Bipolar Disorders

5.1 Depressive Disorders & Bipolar Disorders

Quick Answer: Mood disorders represent disruptions in emotional regulation, categorized broadly into depressive disorders and bipolar spectrum disorders. Major Depressive Disorder requires at least 5 of 9 DSM-5-TR symptoms (SIGECAPS) for at least two weeks, with mandatory depressed mood or anhedonia. Bipolar I is defined by at least one lifetime manic episode (lasting ≥1 week or requiring hospitalization), whereas Bipolar II requires both a hypomanic episode (≥4 days) and a major depressive episode, with no history of full mania. Clinical management demands rigorous suicide risk evaluation (safety planning over no-suicide contracts), psychopharmacological awareness (e.g., MAOI dietary restrictions, lithium toxicity), and evidence-based modalities like CBT, Behavioral Activation, and Interpersonal Psychotherapy (IPT).

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Depressive Disorders

Depressive disorders in the DSM-5-TR are characterized by the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. They differ by duration, timing, and presumed etiology.

Major Depressive Disorder (MDD)

To meet criteria for Major Depressive Disorder, an individual must experience at least five of the following nine symptoms during the same two-week period, representing a clear change from previous functioning. At least one of the symptoms must be either (1) Depressed mood or (2) Loss of interest or pleasure (anhedonia).

Counselors frequently utilize the widely recognized clinical mnemonic SIGECAPS to evaluate the nine DSM-5-TR criteria:

• S — Sleep: Insomnia (middle, terminal, or initial) or hypersomnia nearly every day.
• I — Interest: Markedly diminished interest or pleasure in all, or almost all, activities most of the day (anhedonia).
• G — Guilt: Feelings of worthlessness or excessive, inappropriate guilt (which may be delusional) nearly every day.
• E — Energy: Fatigue or loss of energy nearly every day.
• C — Concentration: Diminished ability to think, concentrate, or make decisions nearly every day.
• A — Appetite / Weight: Significant weight loss when not dieting, weight gain (e.g., a change of more than 5% of body weight in a month), or decrease/increase in appetite nearly every day.
• P — Psychomotor: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• S — Suicidal Ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide.

Bereavement Exclusion Elimination

In the transition from DSM-IV-TR to DSM-5 (retained in DSM-5-TR), the APA removed the formal "bereavement exclusion." Previously, depressive symptoms lasting less than two months following the death of a loved one were automatically attributed to normal grief rather than MDD. In current diagnostic standards, clinicians recognize that severe bereavement can trigger a full major depressive episode. Clinicians differentiate normal grief (feelings of emptiness, waves/pangs of grief tied to memories of the deceased, preserved self-esteem) from major depression (pervasive unhappiness, persistent inability to anticipate happiness, worthlessness, self-loathing).

Diagnostic Specifiers for MDD

• With Anxious Distress: Accompanied by prominent tension, restlessness, worry, and fear of impending doom.
• With Mixed Features: Presence of subthreshold hypomanic/manic symptoms during the depressive episode.
• With Melancholic Features: Near-total loss of pleasure, lack of mood reactivity (mood does not brighten even temporarily when something good happens), profound despondency, depression worse in the morning, early morning awakening, marked psychomotor retardation/agitation, and excessive guilt.
• With Atypical Features: Mood reactivity (mood brightens in response to positive events), accompanied by at least two of: significant weight gain/appetite increase, hypersomnia, leaden paralysis (heavy feelings in arms or legs), and a long-standing pattern of interpersonal rejection sensitivity.
• With Peripartum Onset: Onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery (frequently tested on the NCE; distinct from postpartum "baby blues" which resolve within 10–14 days).
• With Seasonal Pattern (Seasonal Affective Disorder / SAD): Regular temporal relationship between the onset of depressive episodes and a particular time of the year (typically fall or winter) with full remission in spring/summer, persisting for at least 2 consecutive years.
• With Psychotic Features: Delusions or hallucinations present; categorized as mood-congruent (themes of guilt, disease, death, punishment) or mood-incongruent.

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Persistent Depressive Disorder (Dysthymia)

Persistent Depressive Disorder (PDD) represents a consolidation of DSM-IV chronic major depressive disorder and dysthymic disorder. PDD is characterized by chronic depressed mood for most of the day, for more days than not, for at least 2 years in adults (or at least 1 year in children and adolescents, where mood can be irritable).

Diagnostic criteria require the presence of at least two of the following six symptoms while depressed:

1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness

Critical Diagnostic Rule: During the 2-year period (1 year in children/adolescents), the individual has never been without the symptoms for more than 2 months at a time. If criteria for a major depressive episode are continuously met throughout the period, it is coded as PDD with persistent major depressive episode. The clinical term "double depression" describes individuals with baseline dysthymia who experience superimposed major depressive episodes.

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Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder requires that across the majority of menstrual cycles in the preceding year, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

Criteria require at least one symptom from the affective cluster (marked affective lability, marked irritability or anger, marked depressed mood/hopelessness, or marked anxiety/tension) and additional cognitive/somatic symptoms (decreased interest, concentration difficulties, lethargy, appetite changes, hypersomnia/insomnia, feeling overwhelmed, breast tenderness, joint pain, bloating). PMDD is distinguished from normal premenstrual syndrome (PMS) by the severity of distress and functional impairment.

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Disruptive Mood Dysregulation Disorder (DMDD)

Disruptive Mood Dysregulation Disorder was added to DSM-5 to address the dramatic overdiagnosis of pediatric Bipolar Disorder and the consequent overprescription of atypical antipsychotics and mood stabilizers in young children.

Core Diagnostic Criteria:

• Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation.
• Outbursts occur, on average, three or more times per week.
• The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (parents, teachers, peers).
• Symptoms must be present for at least 12 months, without a break of 3 or more consecutive months free of symptoms.
• Symptoms must be present in at least two of three settings (home, school, with peers) and are severe in at least one setting.
• Age Restrictions: The diagnosis cannot be made for the first time before age 6 or after age 18. The age of onset of criteria must be before age 10.
• Differential Hierarchy: DMDD cannot coexist with Oppositional Defiant Disorder (ODD), Intermittent Explosive Disorder, or Bipolar Disorder. If an individual meets criteria for both ODD and DMDD, only DMDD is diagnosed.

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Bipolar and Related Disorders

Bipolar disorders are characterized by cyclic variations in mood, energy, and activity levels, bridging schizophrenia spectrum disorders and depressive disorders in both symptomatology and family history.

Bipolar I Disorder

Bipolar I Disorder requires the occurrence of at least one lifetime manic episode. Major depressive episodes and hypomanic episodes are common in Bipolar I Disorder, but they are not required for the diagnosis under DSM-5-TR.

Manic Episode Criteria:

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
2. During this period, at least three of the following symptoms (four if the mood is only irritable) are present to a significant degree (mnemonic: DIGFAST):
   • D — Distractibility: Attention too easily drawn to unimportant or irrelevant external stimuli.
   • I — Indiscretion / Impulsive Pleasure: Excessive involvement in activities that have a high potential for painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, foolish business investments).
   • G — Grandiosity: Inflated self-esteem or feelings of superiority/grandeur.
   • F — Flight of Ideas: Subjective experience that thoughts are racing, or objective flight of ideas.
   • A — Activity Increase: Increase in goal-directed activity (socially, at work, at school, sexually) or psychomotor agitation.
   • S — Sleep Deficit: Decreased need for sleep (e.g., feels rested after only 2–3 hours of sleep; distinct from insomnia where the individual wants to sleep but cannot).
   • T — Talkativeness: More talkative than usual or pressure to keep talking (pressured speech).
3. The mood disturbance causes marked impairment in social or occupational functioning, necessitates hospitalization to prevent harm to self or others, or involves psychotic features.

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Bipolar II Disorder

Bipolar II Disorder requires the occurrence of at least one hypomanic episode AND at least one major depressive episode. There has never been a manic episode.

Hypomanic Episode Criteria:

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
• Accompanied by at least three symptoms from the DIGFAST criteria (four if mood is only irritable).
• The episode represents an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic, and the disturbance in mood and change in functioning are observable by others.
• Crucial Boundary: The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic, converting the diagnosis to Bipolar I Disorder.

Exam Warning: Bipolar II is not a milder variant of Bipolar I Disorder. Although hypomania causes less acute disruption than mania, individuals with Bipolar II suffer from more frequent, severe, and disabling depressive episodes, spending substantially more lifetime duration in depressive phases, with high rates of completed suicide.

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Cyclothymic Disorder

Cyclothymic Disorder is a chronic, fluctuating mood disturbance lasting for at least 2 years in adults (at least 1 year in children and adolescents). The individual experiences numerous periods with hypomanic symptoms that do not meet full criteria for a hypomanic episode, and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.

• During the 2-year period, hypomanic and depressive periods have been present for at least half the time.
• The individual has not been without the symptoms for more than 2 consecutive months.
• Criteria for a major depressive, manic, or hypomanic episode have never been met.

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Mood Spectrum Comparison Table

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Suicidal Risk Assessment and Clinical Management

Suicide assessment is an indispensable clinical competence tested heavily on the NCE. Mood disorders carry the highest lifetime risk of suicidal behavior among all psychiatric conditions.

Risk Factors vs. Protective Factors

• Static (Demographic/Historical) Risk Factors: Previous suicide attempt (the single strongest predictor of future completed suicide); family history of suicide; male gender (higher rate of completion, typically via lethal means such as firearms); history of psychiatric hospitalization; severe adverse childhood experiences (ACEs).
• Dynamic (Clinical/Modifiable) Risk Factors: Active suicidal ideation with intent and specific plan; access to lethal means (especially firearms in the home); severe agitation and psychic pain; profound hopelessness (measured via Beck Hopelessness Scale; research indicates hopelessness is a more potent predictor of suicide than depression severity alone); active substance intoxication; acute severe insomnia; recent discharge from an inpatient psychiatric unit.
• Protective Factors: Strong therapeutic alliance; internal coping mechanisms; social and community support systems; responsibility to dependent children or pets; cultural or religious beliefs against suicide; restricted access to lethal means.

Evidence-Based Assessment Tools

• Columbia-Suicide Severity Rating Scale (C-SSRS): Standardized screening tool evaluating ideation severity, ideation intensity, and suicidal behavior.
• Beck Depression Inventory-II (BDI-II, Item 9): Evaluates suicidal thoughts.
• Beck Hopelessness Scale (BHS): Evaluates negative expectations about the future.

Clinical Management: The Shift from "Contracts" to Safety Planning

Historically, clinicians utilized "no-suicide contracts" (contracts for safety), wherein clients signed an agreement promising not to harm themselves. Professional counseling standards and contemporary clinical research have firmly discarded no-suicide contracts as ineffective, unsupported by empirical evidence, and providing false legal and clinical security.

The gold standard clinical protocol is the Stanley-Brown Safety Planning Intervention (SPI), a collaborative, hierarchical 6-step plan:

1. Recognize Warning Signs: Identify personal idiosyncratic triggers, thoughts, images, and bodily sensations indicating impending crisis.
2. Internal Coping Strategies: Identify self-soothing and distraction activities that can be executed without contacting another person (e.g., mindfulness, walking, playing an instrument).
3. Social Contacts & Settings for Distraction: Identify people and social venues that offer distraction without disclosing suicidal distress.
4. Trusted Contacts for Support: Identify family members or friends who can be contacted specifically for assistance during a suicidal crisis.
5. Professional Agencies & Crisis Resources: Contact information for personal counselors, psychiatrists, crisis centers, urgent care, and the National Suicide Prevention Lifeline (dial 988).
6. Lethal Means Restriction: Collaboratively identifying and eliminating access to firearms, lethal medications, and sharp objects (e.g., storing firearms locked outside the home with a trusted relative, blister-packing medications).

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Psychopharmacology for Mood Disorders

Counselors must understand the mechanisms, side effects, dietary restrictions, and safety risks of primary medication classes to facilitate client education and multidisciplinary coordination.

Antidepressant Classes

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

• Examples: Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram.
• Mechanism: Selectively block the presynaptic reuptake pump for serotonin (5-HT), increasing synaptic serotonin concentration.
• Clinical Indications: First-line pharmacotherapy for MDD, PDD, OCD, and anxiety disorders due to favorable side effect profiles and safety in overdose.
• Side Effects: Sexual dysfunction (delayed ejaculation, anorgasmia, decreased libido in 40–50% of patients), gastrointestinal distress (nausea, diarrhea), initial anxiety/jitteriness, insomnia, and mild weight gain.
• Black Box Warning: FDA warning regarding increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults (ages 18–24) during the initial 2 to 4 weeks of treatment.
• Serotonin Syndrome: Potentially fatal hyper-serotonergic condition caused by combining serotonergic medications. Symptoms include mental status changes (agitation, confusion), neuromuscular abnormalities (hyperreflexia, clonus, tremors), and autonomic hyperactivity (hyperthermia, tachycardia, diaphoresis).

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• Examples: Venlafaxine, Duloxetine, Desvenlafaxine.
• Mechanism: Inhibit reuptake of both serotonin and norepinephrine.
• Clinical Considerations: Highly effective for depression accompanied by chronic pain syndromes (fibromyalgia, neuropathy) or lethargy. May cause dose-dependent increases in blood pressure.

3. Tricyclic Antidepressants (TCAs)

• Examples: Amitriptyline, Nortriptyline, Imipramine, Clomipramine.
• Mechanism: Inhibit serotonin and norepinephrine reuptake; also block histaminic, cholinergic (muscarinic), and alpha-1 adrenergic receptors.
• Side Effects: Strong anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation, tachycardia), orthostatic hypotension, sedation, and weight gain.
• Lethality Risk: High cardiotoxicity in overdose. TCAs cause fatal cardiac arrhythmias (QTc prolongation, wide complex tachycardia) and heart block. Prescribing large quantities to actively suicidal clients is contraindicated.

4. Monoamine Oxidase Inhibitors (MAOIs)

• Examples: Phenelzine, Tranylcypromine, Isocarboxazid, Selegiline.
• Mechanism: Inhibit the enzyme monoamine oxidase (MAO-A and MAO-B), blocking the breakdown of serotonin, norepinephrine, and dopamine.
• Hypertensive Crisis and Tyramine Diet: MAO in the gut breaks down dietary tyramine. When MAO is inhibited, ingested tyramine enters the bloodstream and triggers massive release of norepinephrine, leading to severe vasoconstriction, explosive occipital headache, palpitations, and potentially fatal hypertensive stroke.
• Dietary Restrictions: Clients must strictly avoid foods containing high levels of tyramine: aged cheeses (cheddar, blue, parmesan), cured/smoked meats (salami, pepperoni), tap/draft beer, red wine (Chianti), sauerkraut, fermented soy products (soy sauce, tofu, miso), and fava beans.
• Washout Period: Switching between an SSRI and an MAOI requires a minimum 14-day washout period (and a 5-week washout period when switching from fluoxetine due to its long half-life) to prevent lethal serotonin syndrome.

Mood Stabilizers

1. Lithium

• Mechanism: Modulates second-messenger systems (adenylyl cyclase, inositol depletion) and neuroprotective factors.
• Clinical Indications: Gold standard for acute bipolar mania, maintenance therapy, and proven reduction of suicide mortality in bipolar patients.
• Narrow Therapeutic Window: Therapeutic serum level is typically 0.6 to 1.2 mEq/L. Levels above 1.5 mEq/L can cause toxicity; levels above 2.0 mEq/L are life-threatening.
• Toxicity Signs: Early toxicity includes coarse hand tremors, nausea, vomiting, persistent diarrhea, ataxia, muscle weakness, and slurred speech. Severe toxicity leads to confusion, seizures, renal failure, coma, and death. Regular laboratory monitoring of serum lithium levels, renal function (BUN/creatinine), and thyroid function (TSH) is mandatory.

2. Anticonvulsant Mood Stabilizers

• Divalproex Sodium / Valproic Acid: First-line for acute mania and mixed episodes. Teratogenic risk (neural tube defects such as spina bifida); requires liver function monitoring.
• Carbamazepine: Effective for rapid-cycling bipolar disorder. Carries risks of aplastic anemia and agranulocytosis; requires regular complete blood counts (CBC).
• Lamotrigine: Primary mood stabilizer for bipolar depression maintenance. Requires slow dose titration due to risk of Stevens-Johnson syndrome (SJS)—a life-threatening dermatological reaction characterized by blistering, epidermal necrolysis, and mucosal ulcerations.

Evidence-Based Psychotherapy for Mood Disorders

1. Cognitive Behavioral Therapy (CBT)

Pioneered by Aaron Beck, CBT posits that depression is maintained by systematic cognitive biases and distorted information processing.

• The Cognitive Triad of Depression: Beck identified three pervasive negative automatic beliefs:
  1. Negative view of the Self: ("I am worthless, unlovable, defective.")
  2. Negative view of the World / Experience: ("The world is demanding, unfair, and hostile.")
  3. Negative view of the Future: ("Things will never improve; hopelessness is inevitable.")
• Cognitive Distortions: Common distortions targeted in counseling include all-or-nothing thinking, overgeneralization, mental filtering, catastrophizing, emotional reasoning, and "should" statements.
• Interventions: Thought records (identifying Situation, Automatic Thought, Emotion, Cognitive Distortion, Rational Response, Outcome), Socratic questioning, decatastrophizing, and collaborative empiricism.

2. Behavioral Activation (BA)

Developed from the behavioral models of Peter Lewinsohn and refined by Neil Jacobson, Behavioral Activation asserts that depression is initiated and maintained by a constriction of positive reinforcement from the environment and increased avoidance behavior.

• Core Mechanism: Depressed individuals engage in withdrawal, rumination, and passivity, which temporarily decreases acute distress but eliminates opportunities to contact reinforcing, pleasurable, or mastery-based experiences, entrenching the depressive spiral.
• Interventions: Activity monitoring, activity scheduling, rating activities on mastery (achievement) and pleasure (enjoyment) on a 0–10 scale, graded task assignments, and breaking avoidance patterns (TRAP: Trigger, Response, Avoidance Pattern → TRAC: Trigger, Response, Alternative Coping).

3. Interpersonal Psychotherapy (IPT)

Formulated by Gerald Klerman and Myrna Weissman, IPT is an empirically validated, structured, time-limited (12–16 sessions) psychotherapy focusing on the interpersonal context in which depression arises and is maintained. Unlike CBT, IPT does not focus on cognitive restructuring; rather, it views depression as a medical illness intertwined with social functioning.

• Four Focus Areas of IPT:
  1. Unresolved Grief: Complicated bereavement following the death of a significant attachment figure; facilitates mourning and finding new relationships.
  2. Role Disputes: Interpersonal conflicts and overt or covert disagreements with a spouse, partner, family member, or coworker; teaches communication analysis and negotiation skills.
  3. Role Transitions: Major life transitions requiring adjustment (e.g., divorce, childbirth, retirement, job loss, beginning college); helps client mourn loss of old role and acquire mastery over new expectations.
  4. Interpersonal Deficits / Sensitivity: Chronic social isolation, lack of enduring relationships, or interpersonal difficulties; focuses on therapeutic relationship dynamics and developing social skills.