Introduction to Affective Disorders

Affective Disorders

This booklet addresses depression (unipolar disorder) and manic depression (bipolar disorder) as treatable medical illnesses. They are not character weaknesses. You can’t develop these disorders from listening to too much Puccini or reading too much Poe. You won’t catch depression from someone else.  And you can’t make yourself better by trying to “snap out of it.”

Depression and manic depressiion are the two major depressive illnesses, also known as affective or mood disorders, because they affect a person’s mood.

In this booklet, we will discuss major depressive disorder and manic depression, which encompass symptoms of depression and mania or hypomania, a less severe form of mania than the acute mania that can occur with bipolar disorder.

You have heard of other forms of depressive illness such as dysthymia, a type of chronic, moderate depression, or cyclothymia, a form of manic depression in which the cycles (mood swings) follow a less extreme pattern of hypomanic and depressive episodes. 

More than 17 million adults in the U.S. suffer from an affective disorderannually–that’s one out of every seven people. Chances are that at some point you, yourself or someone you know will become affected.  If you are a woman, you are twice as likely as a man to experience depression while manic depression affects the sexes equally.   Although these illnesses can occur at any age, they are often triggered between the ages of 25 and 44.

Genetic, biochemical and environmental factors can each play a role in onset and progression. While we all experience occasional highs and lows, affective disorders are characterized by their extremes in intensity and duration. Even at their most intense, the symptoms are often mistaken for other medical problems or dismissed as a reflection of personality, age, social influence or background.

Research indicates that only one-third of those with major depression will are properly treated.  Two-thirds of those with any kind of affective disorder who are treated will be misdiagnosed. These statistics reflect the importance of public and physician education. A lag in diagnosis and treatment could prove deadly; people with severe, untreated depression have a suicide rate as high as 15 percent.

However, of all psychiatric illnesses, affective disorders are among the most responsive to treatment. If given proper care, approximately 80 percent of patients with depression demonstrate significant improvement and lead productive lives.   Successful treatment is also available for people with manic depression;  a substantial number of patients return to a higher quality of life.

Symptoms of Depression

  • Prolonged sadness or unexplained crying spells
  • Significant changes in appetite and sleep patterns
  • Irritability, anger, worry, agitation, anxiety
  • Pessimism, indifference
  • Loss of energy, persistent lethargy
  • Feelings of guilt, worthlessness
  • Inability to concentrate, indecisiveness
  • Inability to enjoy former interests, social withdrawal
  • Unexplained aches and pains
  • Recurring thoughts of death or suicide

Manic depression differs significantly from clinical depression.   In manic-depressive illness, a person’s mood alternates between mania and depression.  The mood swing can last for days, weeks, or even months.  It is important to inform your physician of all mood swings, past or present, so a correct diagnosis can be made.

Symptoms of Mania

  • Heightened mood, exaggerated optimism and self-confidence
  • Decreased need for sleep without fatigue
  • Grandiose delusions, inflated sense of self-importance
  • Excessive irritability, aggressive behavior
  • Increased physical and mental activity
  • Racing speech, flight of ideas, impulsiveness
  • Poor judgment, easily distracted
  • Reckless behavior such as spending sprees, rash business decisions, erratic driving, sexual indiscretions
  • In the most severe cases, hallucinations

Anyone experiencing four or more of the above symptoms of either or both depression or mania should seek help from a medical professional   if symptoms persist for longer than two weeks.

The Cause of Affective Disorders: It’s Not Just in Your Head

Research shows that some people may have a genetic predisposition to affective disorders. If someone in your family has had such an illness, that does not mean you will develop it.  It does increase your chances of experiencing depression with a biological in basis. This is commonly referred to as clinical depression to distinguish it from short-term depressed moods. Even if you don’t have a genetic predisposition, your body chemistry can trigger the onset of a depressive disorder, due to the presence of another illness, altered health habits, substance abuse, or hormonal fluctuations.

Depression can also be triggered by distressing life events, resulting in reactive depression. Repeated disillusionment, from death of a loved one to disappointment in love, can cause anyone to feel depressed.   If these symptoms persist for more than two weeks,  this reactive depression may actually have evolved into a clinical depression.

Regardless of its cause, the presence of depression or manic depression indicates an imbalance in the brain chemicals called neurotransmitters.   Proper treatment will improve your level of functioning and can usually restore you to your “old self.” Many people require ongoing maintenance treatment which significantly decreases the likelihood of recurrences.

Seeking Help

Don’t Let Fear Stand in Your Way

Stigma prevents too many people from getting help in time to prevent acute episodes. Ask your family doctor for a referral to a mental health professional, or inquire at a hospital, medical school, employee assistance program, health department or community mental health center. Your rabbi, minister or pastor may be able to give you a reliable referral as well.

Many people are disappointed to learn that there is no simple diagnostic tool, such as a blood test, to confirm clinical depression or manic depression. However, your doctor should run tests to rule out physical causes such as a thyroid problem, the presence of cancer, chronic fatigue syndrome, a brain injury or even a side effect of medication.

Your Doctor and You:  Be a Partner, Not a Victim

Insist that your doctor treat you as his or her partner in your treatment program. Education will make you a more astute patient–especially when symptoms could cloud your judgment. Apathy associated with depression can make it difficult to follow your doctor’s orders just as the elevated moods of mania fool some patients into believing that they no longer need treatment.

It pays to have a partner outside of the doctor’s office who can help you recognize impaired judgment caused by your illness. Encouragement from a close friend or family member–or even a buddy at work–can help tremendously as you continue your treatment.

As you notice your symptoms, monitor your relationship with your physician and/or mentalh health professional. 
If you aren’t comfortable, don’t be afraid to speak up.  Seek a second opinion or even see someone else. Many people try more than one mental health professional before developing a healthy partnership. Most of us are probably more selective about our choice of hairdresser or mechanic. Yet, what could be more important than your health?

Treatment Options

Medication:  Not Just “Popping Pills”

“I refuse to rely on a pill to solve my problems.” That may be a noble attitude, but one that is not altogether wise.  While a pill may not  make your life better, the right one can improve your ability to cope and restore your   judgment.

The Food and Drug Administration (FDA) has approved several drugs to treat affective disorders. These medications belong to various medication classes.   Each one has a distinctive chemical structure which acts on different receptions in the brain.

Medication Strategies for Depression

For many years, doctors treating depression had very few options to choose from.  The only antidepressants that were available belonged to the tricyclic family:  amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil) and others, and the monamine oxidase inhibitors (MAOIs): trancypromine (Parnate) isocarboxizide (Maarplan) and phenelzine (Nardil).  These products were effective, but sometimes caused unpleasant and even dangerous side effects.

In the 1990s several new antidepressants were approved by the Food and Drug Administration (FDA).  They are equally effective , generally better tolerated and safer than the older medications.  They include:  fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), buproprion (Wellbutrin), venlafaxine (Effexor), nefazodone (Serzone) and mirtazapine (Remeron).

It is important to note that all antidepressants are effective in relieving the overall symptoms of depressoin.  They differ primarily in the side effects they produce.

Medication Strategies for Manic Depession

There are two medications approved for use in manic depression by the FDA.   They are divalproex sodium (Depakote) and lithium (Lithobid, Eskalith, other derivatives).  These medications are known as mood stabilizers.   there are other medications, such as the anticonvulsant carbamazepine (Tegretol), which the FDA has approved for other uses, that are also used to treat manic depression.

If mania is severe, a doctor may prescribe an antipsychotic drug like risperidone (Risperdal), olanzapine (Zyprexa) or thioridazine hydrochloride (Mellaril), in addition to the mood stabilizer to control the symptoms.  In the depressive phase of the disorder, a doctor may prescribe antidepressants.

When Other Medications are Needed:  More Possibilities

Because insomnia and anxiety commonly appear as symptoms or as medication side effects with affective disorders, treatment regimens may also incorporate sedatives/hypnotics or anxiolytics such as benzodiazepines lorazepam (Ativan) or non-benzodiazepines such as solpidem tartrate (Ambien).

Searching for the Right Medication:  Persistence, Patience Pay Off

This luxury of choice increases the necessity of persistence and patience for you and your physician. Determining the proper medication can be a process of trial and error; another person’s wonder drug may have little affect on your body chemistry. It takes an average of four to six weeks, sometimes longer, to accurately determine a medication’s effectiveness.  Some medications must be routinely monitored through simple blood tests which determine if the dosage is at a therapeutic level. If a medication doesn’t seem to be working, or if side effects are intolerable, ask about alternatives.

Your compliance–following doctor’s orders as prescribed–is essential for you and your doctor to find the right treatment. Once you do find the right treatment.  Once that happens, compliance is the only way to be sure that periodic or chronic problems don’t become acute episodes. Be sure you have given your body a chance to react before you decide to stop medication therapy or change doctors—or before you convince yourself that you’ve failed as a patient or that you are somehow destined to feel this way forever.

Frustration with medications can be fueled by side effects which may last a few days or weeks or may linger throughout treatment. Different medication classes have their own side effects, which may include dry mouth, lethargy, tremor, insomnia, agitation, and intestinal irregularity. Ask your doctor what side effects to expect and for how long; there are often natural ways to lessen their intensity.  Your doctor may discover that simply adjusting the dosage solves the problem, but never make these decisions on your own. Always consult your physician. Find out if there are any dietary restrictions.

With MAOIs, certain foods and over-the-counter medications must be avoided.  In all cases, avoid using alcohol as its interaction with medication can be dangerous. Even in moderation, alcohol acts as a depressant, although at first you may feel “perked up.”

Because we all have different bodies, discuss with your doctor the role that your age, gender, weight, overall health and even your ethnic origin may play in the way you metabolize medication. Just as these factors may make a difference in the vitamin supplements you need, so too should your doctor consider the whole person when treating you.

Psychotherapy:  It’s Not Just Talk!

Psychotherapy focuses on treating the person behind the illness.    While medication is often essential to treat the chemical changes in the brain which cause affective disorders, psychotherapy, or “talk therapy,” is an important part of treatment for most patients. It can sometimes work alone in cases of mild to moderate reactive depression or moderate. If you are severely depressed, you may not be able to benefit from psychotherapy until your severe depression has lifted through another means of treatment.

Three types of psychotherapy have proven effective in reducing symptoms. Behavioral therapy concentrates on current behaviors; cognitive therapy focuses on thoughts and beliefs, and interpersonal therapy involves current relationships. A good therapist can help you modify the patterns contributing to your depression. If your disorder appears not to be a function of habit or personality alone, a therapist should refer you to a psychiatrist for evaluation.

Psychotherapists, although highly educated professionals, are not doctors and therefore cannot prescribe medication. You may find a psychiatrist who is skilled in psychopharmacotherapy, the study of both psychotherapy and medication management. Other psychiatrists may work in partnership with a therapist who may be a psychologist, social worker or nurse.

After people with depressive illnesses begin to feel better, they often ask, “If I’m not depressed or manic anymore, why does my doctor want me in psychotherapy?” Psychotherapy can help you understand how the symptoms of affective disorders may have tainted your self-perception and determined how others view you. For instance, someone with frequent mood changes may appear as untrustworthy or insincere.

Those who cry easily or seem overanxious may be dismissed as weak. People who are always “in a bad mood” may even appear less attractive due to tense body language and glum facial expressions. So it’s no wonder that in the vacuum of misunderstanding, people with affective disorders are unfairly judged, losing opportunities to develop friendships or romantic involvements, and even stunting educational and career development. Talking it out, sometimes in concert with other treatment, is a good way to prevent your illness from arresting your personal growth.

From SAD to GLAD:  Light Therapy

The absence of full-spectrum light–light that contains all the wavelengths of natural sunlight–can cause Seasonal Affective Disorder (SAD), a form of depression which typically develops during fall and winter and dissipates during the late spring and summer months. In about half of mild or moderate cases of SAD, symptoms can be alleviated by light therapy, a treatment that exposes patients to a type of full-spectrum light which compensates  daylight loss. This can be a specially designed light box or light visor adaptable for home or office use. In more severe cases. light therapy plus antidepressant medication may be more effective.

Out of the Cuckoo’s Nest:  ECT Today

When medications and psychotherapy fail to adequately alleviate severe depression, ECT, or electroconvulsive therapy, is a safe and effective alternative treatment. It is also used occasionally to interrupt dangerous periods of mania. ECT is usually administered in critical cases where functioning has been dramatically impaired and/or the patient exhibits suicidal behavior.

ECT is not a treatment forced upon people or used as a means of submission. And in no way does it resemble the antiquated treatment depicted in the film One Flew Over the Cuckoo’s Nest. Since its early use in the 1930s, ECT has been refined and improved. Unfortunately, these stigmatizing images prevent some people from considering it as an option.

How does ECT work? Through mild electrical stimulation of the brain, short, modified seizures take place. Muscle relaxants are administered to the anesthetized patient to eliminate pain or shaking. An average of six to twelve treatments over a three to four week period is required. After successful treatment, subsequent depressive episodes may be managed by antidepressants or less frequent “maintenance” doses of ECT.

Like all treatments, ECT has potential side effects. Although there have been reports of memory disturbances, most ECT patients feel that the benefits far outweighed the prospect of suffering from longterm severe, unremitting depression. This is especially true for suicidal patients who may otherwise have tragically carried out their impulses if they had waited for medication therapy to take effect.

Treatment, Not Punishment: When Hospitalization Is Required

In some cases of severe depression or manic depression, physicians may recommend hospitalization for a number of reasons: medication side effects may render one temporarily incapable of safe selfcare; a drug wash (withdrawal from medication) may require a period of controlled observation; people who have attempted or threatened suicide are usually admitted for hospitalization; and severe manic episodes often require aggressive treatment in the safe environment of the hospital.

Regardless of the circumstances, people are not always willing to be hospitalized. Those who are unable to take care of themselves, or who appear to be a threat to themselves or others, must be admitted involuntarily. For information on your state’s legal procedures, contact the patient’s psychiatrist, your state’s attorney’s office, the police, or the hospital emergency room. Involuntary commitment is rare and most often proves to be beneficial.

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