DEPRESSION Major types A.

Major depressive disorder (MDD)characterized by one or more major depressive episodes, which are defined at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression. B. Dysthymic disordercharacterized by at least 2 years of depressed mood for more days than not. Categories of Mood Disorders by DSM-IV-TR A. B. C. D. Depressive disorders Bipolar disorders Mood disorders resulting from a general medical condition Substance-induced mood disorder

Depressive Disorders Depression The oldest and most frequently described psychiatric illness. It can manifest itself is a single or recurrent episode and varies somewhat according to age, race, and gender.

Criteria for MDD 1. 2. 3. 4. 5. 6. 7. 8. 9. Depressed mood Anhedonia Significant change in weight Insomnia or hypersomnia Increased or decreased psychomotor activity Fatigue or energy loss Feelings of worthlessness or guilt Diminished concentration or indecisiveness Recurrent death or suicidal thoughts

Specifiers of MDD A. Atypical depression Generally occurs in younger populations and is more common in women compared in men. This type of depression is expressed by increased appetite or weight gain, hypersomnia, leaden paralysis, and extreme sensitivity to interpersonal rejection. B. Melancholic depression

C.

D.

E.

F.

It is a disturbance of depression occurring most often in older adults that might ne misdiagnosed as dementia. Characterized by anhedonia and an inability to be cheered up. Catatonic features Marked by significant psychomotor alterations, including immobility, excessive motor activity, mutism, echolalia, and inappropriate posturing. Postpartum depression Mood disturbance that occurs during the first 30 days postpartum. More serious than psychotic blues. Psychotic depression Person has delusions, hallucinations in conjunction with the mood disturbance. It is associated with a poorer prognosis compared with other forms of depression. Seasonal affective disorder (SAD) A depression in conjunction with a seasonal change most often beginning in fall or winter and remitting in spring. The higher the latitude, the more likely SAD will occur.

Occurrence in Specific Populations A. Adults a. b. c. d. Most prevalent mental health problems. Depression is predicted to become the leading cause of disability in the future. The average age of adult onset is in the mid- to late 20s. Some individuals will have a single episode of clinical depression, recover, and never become depressed again. e. Five percent to 10% will experience manic phases in addition to depressive episodes. f. Prevalence rates appear unrelated to ethnicity; however, low income groups and individuals with a positive family history of depression are at risk groups. B. Children and Adolescents a. The occurrence is even more devastating than in adults. b. Children of depressed patients are at greater risk of developing the disorder than those who arent clinically depressed. c. Certain events might predispose children and adolescents to develop MDD, including: i. Loss of parents through divorce, separation or death ii. Death of other individuals close to the child iii. Death of a pet iv. Move to another neighborhood or town v. Academic problems or failure vi. Significant physical illness or injury

C. Culture, Age and Gender a. It is known that individuals from certain ethnic racial or cultural groups might express depressive symptoms differently than European Americans. Dysthymic Disorder Dysthymic disorder is essentially a disorder of chronicity whereas severity is the distinguishing factor for MDD. Criteria for dysthymia: o Depressed mood for most of the day, for more days than not. o Presence of two or more of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decision Feelings of hopelessness

Behavior Symptomatic of Depression I. Objective Signs A. Alterations of Activity a. Exhibits psychomotor agitation i. They pace, engage in hand-wringing and might unable to sit still ii. Might pull or rub their hair, clothing or other objects iii. Tying or untying shoes and unbuttoning blouse iv. Psychomotor retardation v. General slowing of body movements vi. The smallest task seems unbearable b. Involvement in activities of ADLs i. Often defer carrying out basic personal hygiene measures ii. Apathy iii. Inability to muster energy to walk to bathroom iv. Changes in eating behaviors v. Changes in sleeping patterns B. Altered Social Interactions a. Poor social skills b. Lack of productivity on the job and at home c. Easily distracted d. Reduces interest in people, ideas or problems e. Problems with thinking, idea development and problem solving f. Conversations are difficult to maintain

g. h. i. j.

Withdrawn Socially isolated Hobbies and avocation become unimportant Body language of depression

II. Subjective Signs A. Alterations of Affect a. Anxiety, doom and gloom, fear, self-destructive thoughts, and panic attacks b. Apathetic c. Sadness d. Low self-esteem e. Full of guilt f. Worthlessness B. Alterations of Cognition a. Ambivalence and indecision b. Inability to concentrate c. Confusion d. Loss of interest and motivation e. Memory problems f. Pessimism g. Self-blame h. Self-deprecation i. Self-destructive thoughts j. Thoughts of death and dying k. Uncertainty C. Alterations of a Physical Nature a. Abdominal pain b. Anorexia c. Chest pain d. Constipation e. Dizziness f. Fatigue g. Headache h. Indigestion i. Insomnia j. Menstrual changes k. n/v l. sexual dysfunction D. Alterations of Perception a. Delusions particularly somatic and nihilistic b. Hallucinations

Biologic Theories of Depression A. B. C. D. E. Neurochemical Theories Genetic Theories Endocrine Theories Circadian Rhythm Theories Changes in Brain Anatomy

PSYCHOLOGICAL THEORIES OF DEPRESSION

1. Psychoanalytic Theories Depression occurs as a result of an early life loss (Freud) Freud viewed aggression as the aggressive instinct inappropriately directed to self

2. Cognitive Theories Depression results when a person perceives all stressful situations as being negative A depressed person reacts to all situations as if they are stressful

3. Interpersonal Theories When a person has interpersonal difficulties, coping with individuals, life events, and life changes can be inordinately stressful and lead to depression

4. Behavioral Theories A person develops depression when he or she develops feelings of helplessness and unworthiness and then learn to use these attitudes to evaluate life outcomes

Three General themes: 1. Debilitating early life experiences Events in early life can lay the foundation for adult depression

Developmental theorists view the early years of life as the foundation of lifelong mental health

2. Intrapsychic Conflict Conflicts people have when they have mixed emotions about a behaviour, event, or situation

3. Reactions of Life Events (Stress) People view depression as a reaction to life stress

ASSESSMENT OF DEPRESSION

Includes: 1. History of onset of symptoms 2. Presence of comorbid substance, alcohol, and medication use 3. Physical Examination 4. Presence of non-mood psychiatric disorders 5. Patient resources and social support systems 6. Interpersonal and coping abilities 7. Level of stressors 8. Presence or level of suicidal ideation

Non-biological Assessment Measures Composed of standardized verbal and written measurement scales

Biologic Assessment Measures Dexamethasone Suppression test Measures the function of the Hypothalamic-Pituitary-Adrenal axis

Urine and blood samples are collected before the test to determine the baseline levels of cortisol. Then, a single injection of the drug dexamethasone is given to the patient. Urine and blood cortisol levels are monitored for 24 hours A positive result occurs when cortisol levels do not fall or return to 5 mcg/dL or higher within 24 hours

Growth Hormone Assessment Used as an assessment measure in childhood depression

Polysomnographic Measurements

- Assessment of sleep patterns - Used to assess depression in adult population - REM stage usually begins within 70 to 100 minutes of a person falling asleep and increases in length throughout the night (Normal) - However, in depressed adults, the REM latency phase is shortened, which results in frequent night and early morning awakening

NURSE-PATIENT RELATIONSHIP

1. Depressed individuals suffer from low self-esteem. The most effective approach to bolster self-esteem is to accept patients as they are, help them focus on the positive, provide successful experiences with positive feedback, keep self-help strategies simple, and help patients avoid embarrassing social blunders 2. Development of a meaningful relationship in which depressed individuals are valued as human beings is important to their sense of personal worth. It is important for the nurse to be honest and to work on developing trust. 3. The nurse who works effectively with depressed patients must have sincere concern for patients and be empathic. 4. It is usually not effective to outline logically why a patient is a worthwhile human being. The nurse can, however, point out even small, visible accomplishments and strengths.

5. Depressed individuals are usually dependent. The nurse should recognize, but not resent, this tendency in depressed individuals. The nurse should reward even small decisions and independent actions. 6. The nurse should not attempt to embarrass the patient out of being depressed. 7. Never reinforce hallucinations, delusions, or irrational beliefs: the nurse cannot agree with delusions, and arguing seems to reinforce them. 8. Depressed individuals tend to be angry. It is important for the nurse to learn to handle hostility therapeutically by recognizing the anger, not by taking it personally and retaliating it in word or deed. 9. The nurse can help withdrawn patients emerge from their social isolation by spending time with them (even without speaking), providing a non-threatening one-to-one relationship, practicing assertive interactions, and being accepting. 10. Depressed individuals can have difficulty in making even simple decisions. It is to therapeutic to badger patients into making decision but it is therapeutic to provide decision-making opportunities as patients are able to comply.

BIPOLAR DISORDER Bipolar disorders are those in which individuals experience the extremes of mood polarity. Individuals might feel very euphoric or very depressed. The current term bipolar disorder is of fairly recent origin and refers to the cycling between high and low episodes (poles). The term "manicdepressive illness" or psychosis was coined by German psychiatrist Emil Kraepelin in the late nineteenth century, originally referring to all kinds of mood disorder. German psychiatrist Karl Leonhard split the classification in 1957, employing the terms unipolar disorder (major depressive disorder) and bipolar disorder. Bipolar disorder, also known as manic-depressive illness, is a brain disorder, which causes unusual shifts of mood, energy, activity levels, and ability to carry out day-to-day tasks. Bipolar disorders in the most intense presentation, the person with bipolar disorder experiences altered thought processes, which can produce bizarre delusions. Average age onset is early 20s for both men and women.

Manic episodes Characterized by elevated, expansive, or irritable mood and are fundamental to the diagnosis of bipolar I disorder. To meet the diagnostic criteria, the symptoms must persist for at least one week or shorter if hospitalization is required.

 It usually begin suddenly, escalate rapidly, and last from a few days to several months. Individuals experiencing manic episode have inflated view of their importance, sometimes reaching grandiosity. They might engage in risky behavior. Manic episodes can be part of other mental disorders or a general medical condition. Patients suffering from a manic episode, the climb up the emotional ladder do not stop in elation, and excessive energy moves into a psychotic thinking and unacceptable behavior. Signs and symptoms: Grandiosity Decreased need of sleep Talkativeness Racing thoughts Distractibility Excessive in: spending spree, sexual indiscretions, loud clothing, and make-up Anger Flamboyant gestures High rate of suicide Hyperactivity Flight of ideas and racing thoughts Increased interest in sex Elevated mood

Medical conditions that cause mania: Anoxia Hyperthyroidism Hemodialysis Lyme disease Hypercalcemia Acquired immunodeficiency syndrome Stroke Brain tumor Multiple sclerosis Normal-pressure hydrocephalus

Hypomanic episodes It is similar to manic episode but denotes a less severe level of impairment. Hypomania is perceived as normal, because patients feel good about themselves and their life. For a hypomanic episode to be diagnosed, the length of episode must be at least 4 days in duration, but not severe enough to warrant hospitalization. It is characterized by an abnormal period of persistent elevated, expansive, or irritable mood. The individual must experience at least three of the following symptoms: Increased self-esteem or grandiosity Decreased need of sleep Subjective sense that thoughts are racing Distractibility Increased in goal-directed activity or motor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences

Depressive episodes Depressive symptoms tends to be atypical Typically develops at a younger age than unipolar depression and the patient is more likely to express paranoid thoughts, be irritable and experience hallucinations. A major depressive episode persists for at least two weeks and may continue for over six months if left untreated. Signs and symptoms: Hypersomnia Hyperphagia Weight gain, Persistent feelings of: sadness, anxiety, guilt, anger, isolation, and hopelessness Loss of interest in usually enjoyable activities Problems concentrating Depersonalization Loss of interest in sexual activity

 Bipolar diagnoses

Shyness or social anxiety Irritability Lack of motivation Morbid suicidal thoughts Delusions Hallucinations Passivity Fatigue Decrease in speech Sluggish thinking Memory loss

DSM-IV-TR (diagnostic and statistical manual of mental disorder fourth edition) bipolar diagnoses are based or an understanding of manic episodes, hypomanic, and major depression.

Bipolar I disorder - The patient experiences swings between manic episodes and major depression. The bipolar I diagnosis can be based on a single manic episode subtype or on several subtypes. These subtypes are: Bipolar I disorder, single manic episode Bipolar I disorder, most recent event a manic episode Bipolar I disorder, most recent event a hypomanic episode Bipolar I disorder, most recent episode mixed (both maniac and depressive symptoms) Bipolar I disorder, most recent episode depressed Bipolar I disorder, most recent episode unspecified

Bipolar II disorder - It is similar to Bipolar I disorder, with a major exception being that the person has never experienced a manic episode but only a hypomanic episode. - The person has experienced major depression but has experience a hypomanic episode, rather than a full manic epidode on the other side of the mood continuum.

Cyclothymic disorder - It is a swing between a hypomanic episode and depressive symptoms. - The swings in either direction are not severe enough to warrant the ultimate diagnoses of manic episode and major depression. - Using a pendulum as a metaphor, the person experiencing Cyclothymic disorder swings from one side to the other but never reaches the extremes of the arc. - The person is elated and expansive but does not meet the criteria for manic episode. - It is characterized by symptoms that have occurred for at least 2 years, without symptom remission for more than 2 months. - The person experiences numerous hypomanic episodes and numerous dysthymic level episodes.

1. What episode is characterized by an elevated, expansive, or irritable mood and are fundamental to the diagnosis of bipolar I disorder? 2. What disorders are those in which individuals experience the extremes of mood polarity? 3. Which of the following is not true about symptoms of manic episode? a. Grandiosity b. Anorexia c. High rate of suicide d. Decreased interest in sex 4. Which of the following is a medical condition that causes mania? a. AIDS b. Asthma c. CVD d. Lupus 5. What disorder is defined as a swing between hypomanic and depressive episode? 1. 2. 3. 4. 5. Manic episode Bipolar disorders D. A. Cyclothymic disoder

Suicide is the intentional killing of oneself. Suicide thoughts are common in people with mood disorders, especially depression. Unlike tightness in the chest, radial arm pain and sweating (warning signs of a possible cardiac event), no similar set of reliable or universal warning signs exists for a pending suicide attempt. Men commit approximately 72% of suicides thats 3 times the rate women although women are 4 times more likely to attempt suicide. The higher suicide rates for men are partly result of the method chosen; shooting, hanging, jumping from a high place. Women are more likely to overdose on medication. Other characteristics of people who commit suicide: A. Age: Suicides are attempted by preteens to the elderly, but rates are highest for between the ages of 15-24 and 45 60. B. Race: Suicide rates are greater for Caucasians or whites than nonwhites. C. Sex: Three times as many men as women succeed at killing themselves. Four times as many women as men attempt suicide. This is because women tend to act impulsively, are relatively public about their attempts, and tend to use relatively less serious means. Men, in contrast, tend to give prior warning signs of their intentions (indicating that the act was not purely impulsive, but thought out in advance), and they use highly effective methods. D. Marital Status: People who are single, divorced or widowed are 2-3 times as likely to commit suicide as married people, especially among men. For married women aged 20 to 30, there is some evidence that they are more likely to attempt suicide than single women. E. Occupational and Educational Status: White collar workers are more likely to commit suicide than blue collar workers. At particular risk are white males with affluent backgrounds for example: psychiatrists, psychologists, physicians and lawyers (Davison & Neale, 1986). In addition, college students who excel in academics are more likely to commit suicide, perhaps because they tend to be the most self-critical (Seiden, 1966; Firestone, 1986). F. Psychiatric History: Individuals who have mental health problems and individuals who have been hospitalized because of such problems are at greater risk for suicide. Especially at risk are those with major depression, bipolar disorder, schizophrenia, substance abuse, post-traumatic stress disorder and borderline personality disorder. Suicidal Ideation means thinking about killing oneself. Active suicidal ideation is when a person thinks about and seeks ways to commit suicide. Passive suicidal ideation is when a person thinks about wanting to die or wishes he or she were dead but has no plans to cause his or her death. Attempted Suicide is a suicidal act that either failed or was incomplete. In an incomplete suicide attempt, the person did not finish the act because: Someone recognized the suicide attempt as a cry for help and responded The person was discovered and rescued Myths and Facts about Suicide people

MYTHS People who talk about suicide never commit suicide

FACTS People who die by suicide usually talk about it first. They are in pain and oftentimes reach out for help because they do not know what to do and have lost hope. Always take talk about suicide seriously. Always. While the self- violence of suicide demonstrates anger turned inward, the anger can be directed toward others in a planned or impulsive action a. Physical harm- e.g. A depressed person may impulsively shoot the person who tries to grab the gun in an effort to stop the suicide b. Emotional harm- e.g. As someone who wants to punish another for rejecting or not returning love Suicide can be prevented. Most people who are suicidal do not want to die; they just want to stop their pain. Suicidal people have already thought of the idea of suicide and may even have begun plans. Asking about suicide does not cause a non-suicidal person to become suicidal. Most people are suicidal for a limited period of time. However, suicidal feelings can recur. No, no, no. They are in pain, and probably have a chemical imbalance in their brain. Anyone could attempt suicide.

Suicidal people only themselves, not others want to hurt

There Is no way to help someone who wants to kill himself or herself Do not mention the word suicide to a person you suspect to be suicidal, because this could give him or her the idea to commit suicide

Once a suicide risk, always a suicide risk

People who attempt suicide are crazy, weal or indifferent

Assessment A history of previous suicide attempts increases risk for suicide. The first 2 years after an attempt represent the highest risk period, especially the first 3 months. Many people with depression who have suicidal ideation lack the energy to implement suicide plans. The natural energy that accompanies increased sunlight in spring is believed to explain why most suicides occur in April. Most suicides happen on Monday mornings, when most people return to work. Warnings of Suicidal Intent Most people who are suicidal put out warning signs to the public as a cry for help. They either directly or indirectly tell or show others about their suicide plan. Direct verbal threats such as "I am going to kill myself," "I am going to swallow a bottle of aspirin," or "By the weekend I will be dead" leave nothing to the imagination. These statements should be taken seriously, no matter how overdramatic they may sound, because very few people make such serious statements for the sake of just being funny. Indirect verbal threats are much more subtle and, therefore, more difficult to pick up on. Indirect threats tend to slide right into regular conversations and may easily be overlooked if one is not aware of these subtle cues. Statements such as "I hate my life," "Sometimes I wish I were dead," or "I just can't go on any longer" are all potential clues that someone may be thinking about suicide and that should lead anyone hearing the statement to act to prevent it. In addition to direct and indirect verbal threats, suicidal people often exhibit a number of behaviors that serve as warning signs. Such signs include sudden changes in behavior related to eating and sleeping patterns, performance at school, physical appearance and hygiene, participation in activities and hobbies, and interactions with friends and family. When people suddenly stop acting like themselves for days or weeks, it is usually a signal that something has gone wrong in their lives and that this behavior should be examined further. Teens who are making plans to die often try to tie up loose ends before they attempt to take their own life. They do this in a number of ways, including giving away the things that matter most to them, getting their rooms organized and their lockers or work spaces cleaned out, returning borrowed materials, and paying loans. These behaviors are not suspicious in and of themselves, but in combination with other suicide warning signs, these acts may serve as signals that the adolescent does not plan to be alive much longer. Finally, teens who suddenly become aggressive, rebellious, or disobedient or who engage in risky or self-destructive behavior are also exhibiting signs that could be related to suicidal intent. These behaviors should not be ignored. Outcome Identification Suicide prevention usually involves treating the underlying disorder, such as mood disorder or psychosis, with psychoactive agents. The overall goals are first to keep the client safe and later to help him or her develop new coping skills that do not involve self-harm. Examples of outcomes for a suicidal person:

 The client will be safe from harming self or others The client will engage in self-therapeutic relationship The client will establish a no-suicide contract The client will create a list of positive attributes The client will generate, test and evaluate realistic plans to address underlying issues Intervention Using an authoritative role The nurse assumes an authoritative role to help clients stay safe. In this situation, clients see few or no alternatives to resolve their problems. For example a client may want to be alone in her room to think privately. This will not be allowed while she is at risk for suicide. Providing a safe environment Inpatient hospitals units have policies for general environment safety. Some policies are more liberal than others, but all usually deny clients access to materials on cleaning carts, their own medications, sharp scissors/objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with strings Initiating a no-suicide contract In such contracts, clients agree to keep themselves safe and notify staff at the first impulse to harm themselves. The urge to commit suicide may return suddenly, so someone must always be available for support. Most suicidal people adhere to no-suicide contracts because they appeal to the will to live. Creating a support system list Suicidal clients often lack social support systems such as relatives, friends, or religious, occupational and community support groups. The nurse makes a list of specific names and agencies that clients can call for support, he or she obtain client consent to avoid breach of confidentiality.

SUBSTANCE INDUCED MOOD DISORDER

A mood disorder is the term given for a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders(DSM IV TR) classification system where a disturbance in the person's mood is hypothesized to be the main underlying feature. The classification is known as mood (affective) disorders.

Mood disorder is a group of disorders characterized by a decrease or entire loss of control over mood. The mood disturbance may occur in different patterns of severity, duration, alone or in combination.

English psychiatrist Henry Maudsley proposed an overarching category of Affective disorder .

The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state whereas the former refers to the external expression observed by others.

Common Etiologic Theories Genetic theory - if one parent has bipolar disorder. 25% chance of transmission to the child

Aggression turned inward theory - over- developed superego leads to depression

Object loss theory - loss of parent before age 11 increase risk of depression

Personality Organization Theory - obsessive - compulsive, oral dependent, hysterical personalities have higher predisposition to mood disorders

Cognitive theory - mood disorder results from (-) view of self, (-)interpretation of experience

Learned Helplessness theory - mood disorder is caused by a belief that one has no control over his environment

Psychoanalytic theory - mania is a defense against an underlying depression (due to rigid superego)

Biologic factor - mania is related to increased norepinephrine while depression is related to low norepinephrine

Common Precipitating Factors loss of loved one major life events roles strain decreased coping resources physiologic changes

Types of Mood disorders 1. Depressive Disorders 2. Bipolar Disorders 3. Substance-induced mood Disorders a. Alcohol-induced mood disorders b. Benzodiazepine-induced mood disorders

Substance-induced mood disorders A mood disorder can be classified as substance-induced if its etiology can be traced to the direct physiologic effects of a psycho active drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Alternately, an individual may have a mood disorder coexisting with a substance abuse disorder. Substance-induced mood disorders can have features of a manic, hypomanic, mixed, or depressive episode. Most substances can induce a variety of mood disorders. For example, stimulants such asamphetamine ( Adderall, Dexedrine; "Speed"),methamphetamine(Desoxyn;"Meth", "Crank", "Crystal", etc.), and cocaine ("Coke", "Crack", etc.) can cause manic, hypomanic, mixed, and depressive episodes. Medications and drugs which can cause substance induced mood disorder include the following: antihypertensives such as reserpine, methyldopa, clonidine, guanethidine,hydralazine, and prazosin hydrodhloride gastrointestinal medications such as cimetidine anticonvulsant medications such as clonazepam

steroids oral contraceptives such as progesterone anti-inflammatory medications such as indomethacin L-dopa antipsychotic medications all sedatives including barbiturates such as phenobarbital, benzodiazepines such as diazepam, meprobamate, methaqualone, gultethimide, elhchlorvynol, chloral hydrate, and ethanol amphetamines (stimulates) methadone heroin cocaine

A. Alcohol-induced mood disorders High rates of major depressive disorder occur in heavy drinkers and those with alcoholism. Controversy has previously surrounded whether those who abused alcohol and developed depression were self-medicating their pre-existing depression, but recent research has concluded that, while this may be true in some cases, alcohol misuse directly causes the development of depression in a significant number of heavy drinkers. High rates of suicide also occur in those who have alcohol-related problems. It is usually possible to differentiate between alcohol-related depression and depression which is not related to alcohol intake by taking a careful history of the patient. Depression and other mental health problems associated with alcohol misuse may be due to distortion of brain chemistry, as they tend to improve on their own after a period of abstinence. B. Benzodiazepine-induced mood disorders Long term use of benzodiazepines which have a similar effect on the brain as alcohol and are also associated with depression. Major depressive disorder can also develop as a result of chronic use of benzodiazepines or as part of a protracted withdrawal syndrome. Benzodiazepines are a class of medication which are commonly used to treat insomnia, anxiety and muscular spasms. As with alcohol, the effects of benzodiazepine on neurochemistry, such as decreased levels of serotonin and norepinephrine, are believed to be responsible for the increased depression. Major depressive disorder may also occur as part of the benzodiazepine withdrawal syndrome. A year after a gradual withdrawal program, no patients had taken any further overdoses. Depression resulting from withdrawal from benzodiazepines usually subsides after a few months but in some cases may persist for 612 months.

Symptoms of Substance induced mood disorder Sadness Emptiness Loss of interest and pleasure Irritability and anger Changes in appetite Sleep problems Restlessness Slow movement and thinking Fatigue Worthlessness and guilt Poor concentration Thoughts about death and suicide Manic Symptoms of Substance induced mood disorder Elation Confidence delusional thinking high level of energy increased activity productivity loud and rapid speech racing thoughts risky behavior impulsive behavior increased sexual behavior over spending fast reckless driving wild business schemes overeating

drinking too much irritability anger aggitation

Diagnosis of Substance-Induced Mood Disorder A. A person has significant disturbance in mood that includes either (or both): 1. Depressed mood or significantly reduced level of interest or pleasure in most or all activities. 2.Mood that is euphoric, heightened, or irritable.

B. The person's symptoms develop during (or within four weeks of) intoxication or withdrawal, or are caused by medication use.

C. Another disorder does not better explain the mood disturbance.

D. The mood condition is not present only when a person is delerious.

E. The symptoms are a cause of great distress or difficulty in functioning at home, work, or other important areas.

Treatment for substance induced mood disorder Should begin with a medical evaluation and medically supervised detoxification (if indicated) from the substance. psychotherapy should be used to help the individual establish recovery from any addiction which may be present. Psychological treatment must help the persons development of adequate coping skills as well.

SEASONAL AFFECTIVE DISORDER

Seasonal affective disorder (SAD), also known as winter depression, winter blues, summer depression, summer blues, or seasonal depression, is a mood disorder in which people who have normal mental health throughout most of the year experience depressive symptoms in the winter or summer, spring or autumn year after year.

Symptoms Symptoms of SAD may consist of difficulty waking up in the morning, morning sickness, tendency to oversleep and over eat, especially a craving for carbohydrates, which leads to weight gain. Other symptoms include a lack of energy, difficulty concentrating on or completing tasks, and withdrawal from friends, family, and social activities and decreased sex drive.

Diagnostic Criteria Seasonal Affective Disorder is not regarded as a separate disorder. It is called a "course specifier" and may be applied as an added description to the pattern of major depressive episodes in patients with major depressive disorder or patients with bipolar disorder. The "Seasonal Pattern Specifier" must meet four criteria: depressive episodes at a particular time of the year; remissions or mania/hypomania at a characteristic time of year; these patterns must have lasted two years with no non seasonal major depressive episodes during that same period; and these seasonal depressive episodes outnumber other depressive episodes throughout the patient's lifetime. In the popular culture, sometimes the term "seasonal affective disorder" is applied inaccurately to the normal shift to lower energy levels in winter, leading people to believe they have a physical problem that should be addressed with various therapies or drugs.

Treatment There are many different treatments for classic (winter-based) seasonal affective disorder, including light therapy, medication, ionized-air administration, cognitive-behavioral therapy and carefully timed supplementation of the hormone melatonin.

Photoperiod-related alterations of the duration of melatonin secretion may affect the seasonal mood cycles of SAD. This suggests that light therapy may be an effective treatment for SAD. Light therapy uses a lightbox which emits far more lumens than a customary incandescent lamp. Bright white "full spectrum" light at 10,000 lux, blue light at a wavelength of 480 nm at 2,500 lux or green (actually cyan or blue-green) light at a wavelength of 500 nm at 350 lux are used, with the first-mentioned historically preferred.

Bright light therapy is effective with the patient sitting a prescribed distance, commonly 30 60 cm, in front of the box with her/his eyes open but not staring at the light source for 3060 minutes.

Light therapy can also consist of exposure to sunlight, either by spending more time outside or using a computer-controlled heliostat to reflect sunlight into the windows of a home or office.

SSRI (selective serotonin reuptake inhibitor) antidepressants have proven effective in treating SAD. Bupropion is also effective as a prophylactic. Effective antidepressants are fluoxetine, sertraline, or paroxetine. Both fluoxetine and light therapy are 67% effective in treating SAD according to direct head-to-head trials conducted during the 2006 Can-SAD study. Subjects using the light therapy protocol showed earlier clinical improvement, generally within one week of beginning the clinical treatment.

Negative air ionization, which involves releasing charged particles into the sleep environment, has been found effective with a 47.9% improvement if the negative ions are in sufficient density.

Another explanation is that vitamin D levels are too low when people do not get enough Ultraviolet-B on their skin. An alternative to using bright lights is to take vitamin D supplements. However, one study did not show a link between vitamin D levels and depressive symptoms in elderly Chinese.