Disordered Mood in Cultural-Historical Context

The research literature on mood disorders is dominated by Western concepts. Historical changes and cultural variations are the focus of this chapter. We begin with a historical overview, then turn to the contemporary literature on cultural variations in mood disorders, focusing on: (1) etiological beliefs, (2) risk and resilience, (3) incidence and prevalence, and (4) symptoms. We propose an approach to understanding cultural variations in psychopathology based on a core idea from cultural psychology: the mutual constitution of culture, mind, and brain. Then, we describe some of the ways symptoms of disordered mood can be understood as emerging from looping processes in the culture-mind-brain system. For future research, we emphasize the importance of integrative studies across culture-, mind-, and brain-levels. Then we consider the possibility that historical changes in descriptions of disordered mood might include culturally shaped transformations in normal and abnormal experience.

Psychosocial Approaches to the Treatment and Prevention of Bipolar Disorder

Over the past two decades, adjunctive psychosocial treatments for bipolar disorder have been shown to hasten recovery, reduce relapse, and improve patients’ medication adherence, functioning, and quality of life. This chapter reviews four of the most widely studied psychosocial approaches for bipolar disorder: psychoeducation, cognitive-behavioral therapy (CBT), family-focused treatment (FFT), and interpersonal and social rhythm therapy (IPSRT). Core treatment strategies for each modality are presented, and key outcome studies are reviewed. The role of psychosocial treatment in pediatric bipolar disorder and in the prevention of bipolar disorder in youth at high risk for bipolar disorder is also presented. Suggestions for future research and the critical need for dissemination are also briefly discussed.

Introduction

This volume provides what we believe to be the most comprehensive treatment of the range of mood disorders to date. In this introductory chapter, we present the organization and overarching themes of the volume. The volume’s coverage of mood disorders includes historical, cross-cultural, developmental, neuroscientific, etiological, and therapeutic issues. Following this introduction (Section I), Section II provides coverage of the phenomenology, classification, and assessment of mood disorders. A key theme of the section, the heterogeneity of mood disorders, is then carried through the volume. Section III addresses key etiologic, vulnerability and risk factors. Section IV covers key interpersonal and intra-personal factors, with several chapters focusing on neurobiological features. Section V examines variants of mood disorders as well as key sub-populations. Section VI addresses common comorbidities. Finally, Section VII surveys the wide array of commonly used and evidence-based treatment and prevention approaches.

Brain Stimulation Treatments for Depression

The use of brain stimulation for the treatment and investigation of mood disorders is rapidly expanding. Mood disorders are common, but so are treatment-refractory or intolerant patients, explaining increasing interest in alternatives to medications and talk therapy. Additionally, depressive episodes are periodic or temporary states and are thus amenable to pulsatile, non-systemic treatments. The oldest brain stimulation method, electroconvulsive therapy (ECT), remains the most effective acute antidepressant available. The newer brain stimulation methods, in particular repetitive transcranial magnetic stimulation (rTMS), also show that non-invasive stimulation of key brain regions not only effectively treats depression, but also causes quantifiable changes in brain biomarkers. More research is needed, though, to better understand how these treatments work, for whom they work, and how to optimize their use.

Genetics of Bipolar and Unipolar Disorders

Bipolar and unipolar mood disorders are common, chronic illnesses with high morbidity and mortality. This chapter reviews evidence of heritable components of risk from twin, family, adoption, and molecular studies. Heritability (that fraction of risk due to germline DNA variation) of bipolar disorders is estimated at 65–80%, while unipolar disorders heritability is less, ~40%. Genome-wide association studies of bipolar disorder have identified several risk alleles in brain-expressed genes, including ankyrin 3 and a subunit of an L-type calcium channel. Similar studies of unipolar disorders have yielded evidence for risk alleles, probably due to inadequate sample sizes, given the lower heritability of this disorder. Both disorders are characterized by shared genetic susceptibility with other psychiatric nosologic categories, including schizophrenia and attention deficit disorder. The molecular studies have indicated that both disorders are polygenic, with hundreds of common susceptibility alleles, each conveying a very small amount of risk.

Suicide

Suicide represents a growing public issue that involves great emotional cost and loss of life. This chapter provides an academic overview of the topic of suicide. Methods of classification and definitional issues are discussed. Epidemiological trends in rates of suicide and suicide attempts are well established and are reported. The phenomenology of suicidal behavior represents an under-studied area and there is discussion of the few studies that exist and possibilities for future investigations in this area. Next, the etiology of suicide in the context of current suicide theory, including the interpersonal theory of suicide, is discussed. This essay concludes with a practical discussion of clinical risk assessment for suicidal behavior and future recommendations for research.

Cognitive Therapy of Depression

We provide an overview of cognitive therapy (CT) of depression, including its treatment procedures, therapeutic effects, and mechanisms of change, as well as its effectiveness and dissemination. CT is a well-established treatment with acute effects on par with those of medication. Unlike medication, CT appears to have effects that endure after treatment ends. Although definitively establishing CT’s mechanism of action is difficult, the available evidence is consistent with the possibility that CT achieves its effects partly through cognitive change. Despite potential challenges in generalizing research findings on CT into clinical practice, initial evidence of the effectiveness of CT has been promising. Finally, we discuss efforts to disseminate CT, along with our thoughts on future research directions.

Phenomenology and Course of Mood Disorders

In this chapter, we provide an overview of the phenomenology of the mood disorders, including attention to both symptoms and functional impairment. Our overview emphasizes the heterogeneity among those with these disorders, as well as the most influential approaches to describing this variability across and within bipolar and depressive disorders. We discuss the degree of overlap between bipolar and depressive disorders, paying special attention to the clinical significance of low levels of manic symptoms. We also review several influential symptom-based specifiers, including those that refer to melancholic, atypical, anxious, and psychotic features. Having considered variability in the symptoms of these disorders, we then consider the course of these disorders. We survey the remarkable variability in course as well as current approaches to characterizing these differences. We conclude with a discussion of future directions.

Mood Disorders in Late Life

This chapter discusses how clinicians will need to prepare for a worldwide exponentially growing aging community by describing the current scope of practices with respect to the assessment and treatment mood disorders, including minor and major depression. Particularly for those in later life, the meaningful interpretation of standardized assessment scores requires consideration of medical and neurological complexities. Clinicians must be flexible not only with respect to characterization, but especially with respect to treatment, given the inherent challenges associated with access to care and the range of disability amongst these individuals. Indeed, these late-life individuals are typically assessed in a similar fashion to younger adults (which may obscure meaningful interpretations), making understanding the nuances underlying existing behavioral and pharmaceutical approaches an essential endeavor.

Behavior Therapy of Depression

This article discusses the three primary contemporary behavior therapy interventions for depression: problem-solving therapy (PST), coping with depression (CWD), and behavioral activation (BA). After providing an overview of the historical roots of behavioral treatment for depression, the article describes the theoretical foundation of each approach. It then considers the evidence base, citing clinical trials that have evaluated the efficacy and effectiveness of PST, CWD, and BA. It also examines the primary treatment strategies of each approach and concludes by suggesting directions for future research that emphasize the need to clarify mechanisms of change and to extend the scope of behavioral therapy for depression.