By Stephen J. Johnson, Ph.D.
Introduction
In Part I of my three-part series on depression titled, When Depression Turns Deadly: The Mask Men Wear, I focused more specifically on the hidden depression in men and how to recognize it before it ravages your life. The tragic loss of a loved one by suicide is often the end result of a life long battle with unremitting depression. Learn how to recognize the signs and treat the problem before it’s too late. In Part II, Depression in Men and Women: Recognizing and Understanding the Condition, I discussed the two main forms of depression, the causes and common symptoms of Major Depressive Disorder as distinguished from Persistent Depressive Disorder (Dysthymia), its occurrence in men and women, how depression can turn violent and what needs to be done to weatherproof your life as a hedge against the condition. In this, the third part of the series, I provide information on childhood Disruptive Mood Dysregulation Disorder, Bipolar and Cyclothymic Disorders, a selfevaluation depression checklist, standard medical and alternative treatment modalities, and how to help yourself and others heal from the condition.
With an intention to provide some of the salient features of depression to help the reader to more readily recognize and distinguish the condition, I am synthesizing in some information from the Diagnostic and Statistical Manual of Mental Disorders (DSM) that is essentially the clinical bible that mental health practitioners utilize. The fifth edition of the DSM was published in 2013 and is a vital resource for understanding and diagnosing mental disorders. Since it is not my intention to provide a complete clinical analysis of the conditions mentioned herewith I recommend that for further and more in depth clinical information please refer to the DSM-5.
Disruptive Mood Dysregulation Disorder
The core feature of this disorder is chronic, severe persistent irritability. There are two prominent features, the first of which is frequent temper outbursts which typically occur in response to frustration and express as verbal or behavioral acting out against property, self or others. They occur frequently and over a period of at least a year in more than one setting, i.e. at home and school. The second feature is a pervasively angry mood that is present between the severe temper outbursts.
This diagnosis was added to the DSM-5 to address the concern about the appropriate classification and treatment of children who present with chronic persistent irritability as distinct from those who present with classic bipolar disorder. Disruptive Mood Dysregulation Disorder is common among children who are treated at pediatric mental health clinics.
The onset of this disorder must be before age 10 years, and not applicable before developmental age of less than 6 years. This condition is more common than bipolar disorder prior to adolescence, and symptoms of the condition generally become less common as children transition into adulthood. Many children with this condition have symptoms that also meet the criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) and for Anxiety Disorder. For some children, the criteria for Major Depressive Disorder (MDD) may also be met.
This condition is associated with with a marked disruption in a child’s family and peer relationships, as well as in school performance. Those with this disorder have trouble initiating or sustaining friendships.
Bipolar Disorders (two subtypes)
A. Bipolar 1 Disorder – The essential feature of this disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. A
Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood. This period of abnormal mood must last at least 1 week. The mood disturbance must be accompanied by at least three additional symptoms from a list that includes inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences.
The elevated mood of a Manic Episode may be described as euphoric, unusually good, cheerful, or high. Although the person’s mood may initially have an infectious quality for the uninvolved observer, it is recognized as excessive by those who know the person well. The expansive quality of mood is characterized by unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupation interactions.
The mean age at onset for a first Manic Episode is the early 20’s, but some cases start in adolescence and others start after age 50 years. Manic Episodes typically begin suddenly, with a rapid escalation of symptoms over a few days. The episodes usually last from a few weeks to several months and are briefer and end more abruptly than MDE. In many instances (50%-60%), a MDE immediately precedes or immediately follows a Manic Episode, with no intervening period of euthymia (a joyful yet tranquil mood).
A Mixed Episode is characterized by a period of time (lasting at least 1 week) in which the criteria are met both for a Manic Episode and for a MDE nearly every day. The individual experiences rapidly alternating moods (sadness, irritability, euphoria) accompanied by symptoms of a Manic Episode and a MDE. The symptom presentation frequently includes agitation, insomnia, appetite dysregulation, psychotic features, and suicidal thinking. Mixed episodes appear to be more common in younger individuals and in individuals over age 60 years with Bipolar Disorder and may be more common in males than in females.
Completed suicide occurs in 10%-15% of individuals with Bipolar 1. Child abuse, spouse abuse, or other violent behavior may occur during severe Manic Episodes or during those with psychotic features. Other associated problems include school truancy, school failure, occupational failure, divorce, or episodic antisocial behavior. Other associated mental disorders include Anorexia Nervosa, Bulimia Nervosa, Attention-Deficit/Hyperactivity Disorder, Panic Disorder, Social Phobia, Substance Related Disorders.
There are no reports of differential incidence of Bipolar 1 Disorder based on race or ethnicity. Approximately 10%-15% of adolescents with recurrent MDE will go on to develop Bipolar 1 Disorder. Mixed Episodes appear to be more likely in adolescents and young adults than in older adults. Recent epidemiological studies in the US indicate that Bipolar 1 Disorder is approximately equally common in men and women (unlike MDD which is believed to be more common in women). Gender differences is related to the order of appearance. The first episode in males is more likely to be a Manic Episode. The first episode in females is more likely to be a MDE.
Bipolar 1 Disorder is a recurrent disorder more than 90% of individuals who have a single Manic Episode go on to have future episodes. Roughly 60%70% of Manic Episodes occur immediately before or after a MDE.
First-degree biological relatives of individuals with Bipolar 1 Disorder have elevated rates of Bipolar 1 Disorder (4%-24%), Bipolar II Disorder (1%-5%),
and MDD (4%-24%). Twin and adoption studies provide strong evidence of a genetic influence for Bipolar 1 Disorder.
B. Bipolar II Disorder – ( Recurrent Major Depressive Episodes with Hypomanic Episodes) The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more MDE accompanied by at least one Hypomanic Episode. A Hypomanic Episode is defined as a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood that lasts at least 4 days. This period of abnormal mood must be accompanied by at least three additional symptoms from the list of symptoms characteristic for Manic Episodes. The list of symptoms is identical to those that define a Manic Episode except that delusions or hallucinations cannot be present. The mood during a Hypomanic Episode must be clearly different from the individual’s usual non depressed mood, and there must be a clear change in functioning that is not characteristic of the individual’s usual functioning. In contrast to a Manic Episode. A Hypomanic Episode is not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization, and there are no psychotic features.
A Hypomanic Episode typically begins suddenly, with a rapid escalation of symptoms within a day or two. Episodes may last for several weeks to months and are usually more abrupt in onset and briefer than MDE. In many cases, the Hypomanic Episode may be preceded or followed by a MDE. Studies suggest that 5%-15% of individuals with hypomania will ultimately develop a Manic Episode. Hypomanic Episodes should not be confused with the several days of euthymia that may follow remission of a MDE.
The presence of a Manic or Mixed Episode precludes the diagnosis of Bipolar II Disorder. Individuals with Bipolar II Disorder may not view the Hypomanic Episodes as pathological, although others may be troubled by the individual’s erratic behavior. Often individuals, particularly when in the midst of a MDE, do not recall periods of hypomania without reminders from close friends or relatives.
Roughly 60%-70% of the Hypomanic Episodes in Bipolar II Disorder occur immediately before or after a MDE. Hypomanic Episodes often precede or follow the MDE in a characteristic pattern for a particular person. The number of lifetime episodes (both Hypomanic Episodes and MDE) tends to be higher for Bipolar II Disorder compared with MDD, Recurrent. The interval between episodes tends to decrease as the individual ages. Approximately 5%-15% of individuals with Bipolar II Disorder have multiple (four or more) mood episodes (Hypomanic or Major Depressive) that occur within a given year. If a Manic or Mixed Episode develops in the course of Bipolar II Disorder, the diagnosis is changed to Bipolar 1 Disorder. Over 5 years, about 5%-15% of individuals with Bipolar II Disorder will develop a Manic Episode.
Some studies have indicated that firstdegree biological relatives of individuals with Bipolar II Disorder have elevated rates of Bipolar II Disorder, Bipolar I Disorder, and MDD compared with the general population.
Cyclothymic Disorder – The essential feature of this disorder is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. The hypomanic symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a Manic Episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, or duration to meet full criteria for a MDE. The diagnosis of Cyclothymic Disorder is made only if the initial 2year period of cyclothymic symptoms is free of Major Depressive, Manic, and Mixed Episodes.
Cyclothymic Disorder often begins early in life and is sometimes considered to reflect a temperamental predisposition to other Mood Disorders (especially Bipolar Disorders). In community samples, Cyclothymic Disorder is apparently equally common in men and in women. In clinical settings, women with Cyclothymic Disorder may be more likely to present for treatment than men.
MDD and Bipolar 1 or II Disorder appear to be more common among firstdegree biological relatives of persons with Cyclothymic Disorder than among the general population. There may also be an increased familial risk of SubstanceRelated Disorders.
Are You Depressed?
Disclaimer: The following information, including this evaluation tool, is not intended to provide medical advice or diagnosis. It is intended for educational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. You should never ignore or not seek professional medical advice when indicated. If you or someone you know is thinking about suicide you should contact a mental health professional immediately or call the National Suicide Prevention Hotline at 1-800-272-TALK(8255).
This simple, short questionnaire may help you better understand the depression symptoms that are possibly affecting your life. It was developed by Drs. Robert L. Spitzer, Janet B. W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. After answering all the questions, you may wish to share your answers with your doctor.
Instructions: Over the last two weeks, how often have you been bothered by any of the following problems. Place a mark in the box that corresponds to your response.
1. Little interest or pleasure in doing things.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
2. Feeling down, depressed or hopeless.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
3. Trouble Falling or staying asleep, or sleeping too much.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
4. Feeling tired or having little energy.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
5. Poor appetite or overeating.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
7. Trouble concentrating on things, such as reading the newspaper or watching television.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
9. Thought that you would be better off dead or of hurting yourself in some way.
[ ] Not At All [ ] Several Days [ ] More Than Half The Days [ ] Nearly Every Day
Scoring After completing the PHQ9 questionnaire, designate the following values for each of the checked boxes: Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Add them up to arrive at a total score.
[ 0 ] + [ ] + [ ] + [ ] Total = [ ]
Interpretation of Total Score
0-4 = Minimal depression
5-9 = Mild depression
10-14 = Moderate depression
15-19 = Moderately severe depression
20-27 = Severe depression
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all [ ]
Somewhat difficult [ ]
Very difficult [ ]
Extremely difficult [ ]
Standard Medical Treatment
If you or someone you know is suffering from symptoms of depression, a professional evaluation and treatment is recommended. In some cases counseling may be enough to resolve the issues causing one’s depressed and anxious mood. In many cases individuals can be treated with a combination of therapy and medication. A licensed psychotherapist can provide the counseling and a psychiatrist can provide the psychopharmacology. Clinical depression is often the result of an imbalance of one’s neurotransmitters such as serotonin, dopamine, norepinephrine and oxytocin.
Neurotransmitters are chemicals released by the brain that regulate mood as well as mental and physical functionality.
There are many new medications on the market that are highly effective and have minimal side effects. Antidepressants such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) block reabsorption allowing the brain to have greater use of available neurotransmitters. For depression that is caused by low serotonin levels, SSRls, such as Prozac, Zoloft, Lexapro are among those that are most widely prescribed. Wellbutrin is an excellent medication when an individual’s dopamine level is low. Effexor and Serzone are good SNRI medications for balancing out the spectrum including serotonin and norepinephrine levels. Often, psychiatrists will prescribe more than one medication to be used in combination for stabilizing and balancing a patient’s mood.
The general rule of thumb is for one, when it is recommended, to go on a course of antidepressant medication(s) for a minimum of a year. It may be determined that the conditions underlying the depression have been resolved to the degree that the medication may be reduced or discontinued after a year of treatment. It may also be determined that one is better off by maintaining a regimen of medication for an extended period of time to mitigate against a return of symptoms. In the case of a more chronic and acute condition, it’s important to work in combination with a psychiatrist to make the wisest medication decisions for sustaining health and well-being.
Alternative Treatment Modalities and Over-the-Counter Supplements
In the realm of alternative treatment there is a growing interest in the benefits of over-the-counter supplements and herbs as well as homeopathic and ayurvedic remedies. It is important to remember that just because a supplement may be obtained without a prescription, it does not prevent potential side-effects from misuse or even recommended use. Experimenting with over-the-counter supplements should always be commenced with as much cautionary discernment and informed advice as possible.
SAM-E (Sadenosylmethionine),5-HTP(5Hydroxytryptophan) and St. John’s Wort may be used in treating more mild forms of depression where serotonin is out of balance. SAM-E has been used widely over the years in Europe to help support a healthy mood including joint comfort and has been available in the U.S. for several years now. 5-HTP can also be helpful in promoting a calm and relaxed mood and help with control of appetite. St. John’s Wort, an herb, had been at one time the most widely prescribed antidepressant in Germany. People, taking 300 mg. capsules 3 x per day for serotonin enhancement have experienced satisfactory results. One of the benefits of taking herbs is that they are inexpensive. Whereas a month’s supply of a prescription medication could cost from $25 to $250 or more, 60 capsules of St. John’s Wort costs approximately $9. Another benefit is that one side effect of SSRI’s affecting 30%-50% of patients, decreased libido and inability to orgasm, is not typically experienced when using SAM-E, 5-HTP or St. John’s Wort. St. John’s Wort can render one more sensitive to sunlight, so it’s important to be mindful when it comes to prevention for skin cancers and cataracts.
Taking three 475 mg. capsules of Gotu Cola per day has been reported to elevate one’s norepinephrine level thereby producing more natural energy. There are those who suggest that taking Ginkgo Biloba provides more oxygen to the brain and is helpful for mental alertness and assistance in focusing which is often a problem with those suffering from Attention Deficit Disorder, with or without hyperactivity. This condition affects approximately 9 million American adults and children. I will not go into the causality and treatment of ADD/ADHD in this paper, however, it is worth mentioning that there is often a depressed mood experienced by those who have this disorder. Ginkgo Biloba has also been reported as diminishing or mitigating the sexual side effects of an SSRI.
Folic acid, which provides the body with folate, a vitamin that helps produce red blood cells, may be instrumental in treating depression. A Harvard Medical School study of more than 200 depressed women and men discovered that patients with low folate levels in their blood were more severely depressed and less likely to respond to certain antidepressant medications like Prozac than those with normal folate levels.
For patients who do not respond to antidepressants alone, the study suggests that folic acid supplements might be useful in conjunction with and an SSRI. There is research that L-methylfolate
is the only form of folate that the brain can use to regulate the neurotransmitters associated with depression. The L-methylfolate found in a new medical food called Deplin is touted as providing the nutritional requirements to dietarily manage depression by supplying the brain with the L-methylfolate it needs to make the neurotransmitters that regulate mood.
For those that have inveterate depression that has been unremitting, when therapy and medication have not been as effective to interrupt the pattern, the patient may wish to explore more neuro-scientific evaluation and treatment. Brain-mapping, neuro-feedback training and TMS (Transmagnetic Stimulation, consisting of several hourlong treatments that focus a highpowered
magnet on certain areas of the brain, such as the region that regulates “hopefulness”) may also be helpful. In extreme cases, one or more ECT (Electroshock Treatment) sessions may be necessary to interrupt a severely immobilizing MDE.
Helping Yourself or Someone You Know
Depressive disorders can make you feel exhausted, worthless, helpless and hopeless. But these feelings are part of the depression and will fade as treatment begins to take effect. In the meantime:
1. Do not set difficult goals or take on a great deal of responsibility.
2. Break large tasks into small ones, set priorities and do what you can as you can.
3. Do not expect too much from yourself too soon.
4. Try to spend time with other people.
5. Participate in activities that may make you feel better. Try mild exercise, going to a movie (especially a comedy), a ball game, or participating in religious or social activities.
6. Don’t get upset if your mood is not greatly improved right away. Feeling better takes time. Do not make major life decisions, such as whether or not to change jobs, or get married or divorced, without consulting others who know you and your situation well. Try to postpone such decisions until your depression has lifted.
7. See a professional consultant (family physician, psychiatrist or psychotherapist) for an evaluation of your condition.
Helping another – The most important thing you can do for a depressed person is to help him or her get appropriate evaluation and treatment. This may mean making an appointment and accompanying the depressed person to the doctor. It may mean encouraging the person to continue treatment or to seek different treatment if no improvement occurs. It may also mean monitoring whether or not the depressed person is taking medication as prescribed.
It is also important to offer emotional support understanding, patience, affection and encouragement. Listen kindly and carefully. Do not belittle the person’s feelings, but gently try to offer an objective, positive view. Keep reassuring the depressed person that, with time and help, he or she will feel better. Do not accuse the depressed person of faking illness; do not demand that he or she “snap out of it.” And never ignore remarks about suicide seek professional help immediately.
This three-part series on depression is offered to familiarize and educate the reader in recognizing the range of how depression presents symptomatically. Additionally, the intention is to further offer some reasonable solutions for treating and resolving the condition(s) before it manifests so severely that it wreaks havoc with your life and the lives of your loved ones. I trust that you have found value in the information.
Information for this three-part series on depression was extracted from the following sources:
Article – “Depression: Finding Hope and Healing” published in Better Health for Today’s Family, Fall Newsletter from UCLA Neuropsychiatric Institute and Hospital.
Article – “The Sad Truth About Men”, by Pamela Warrick, Staff Writer for Los Angeles Times, Section E, Monday, February 10, 1997.
I Don’t Want to Talk About it: Overcoming the Secret Legacy of Male Depression by Terrence Real, Fireside,1997.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Washington, DC, 2013.
This article, or parts of it, may be quoted or reproduced with permission. Please contact the author at: DrJ@DrStephenJohnson.com