MOOD DISORDERS

MOOD
DISORDERS
 Definition

• Mood Disorders describes a group of disorders

with the essential feature of a disturbance in
mood that is not due to any other mental or
physical disorder, medication, substance use, or
other psychotic condition
• DSM-IV-TR  MOOD DISORDERS
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bipolar disorders depressive disorders

Presence of one or more One or more periods of

manic episodes (often depression, but not
with a history of at least necessarily with a manic
one major depressive episodic history
episode
• Dysthymia: is a milder form of major depressive episode,
but it lasts for a longer period of time

• Cyclothymia: a milder form of bipolar disorder, and it

also has a longer duration

Bipolar and depressive disorders range from mild to

severe and may include psychotic features

They usually cause considerable distress and/or

impairment in all occupational areas of functioning
Signs and Symptoms
 Major Depressive Episode
At least 5 of the following symptoms must be present for 2 weeks
and represent a change from previous level of functioning

1) Daily depressed mood

2) Very marked decrease of interest or pleasure in most daily activities
3) Significant weight loss or weight gain
4) Inability to sleep or sleeping most of the day
5) Psychomotor agitation or psychomotor retardation
6) Extreme fatigue or loss of energy
7) Feelings of extreme worthlessness or inappropriate guilt nearly
every day
8) Indecisiveness or lack of concentration
9) Suicidal ideation
 Manic Episode
There is a distinct period of abnormal, elevated, expansive,
or irritable mood lasting at least one week. At least 3 or
more of the following symptoms are significantly present:
1) Grandiosity or overinflated self-esteem
2) Decreased need for sleep
3) Talking more than usual or pressured talking
4) The experience that thoughts are racing
5) Extreme distractibility
6) Increase in goal-directed activity or psychomotor
agitation
7) Excessive involvement in pleasurable activities that have
the potential for later painful consequences
 Hypomanic Episode
• Elevated mood must last at least four days

• Include three of the symptoms of mania

• The episode does not cause marked impairment

in occupational and social functioning

• Does not include psychotic features

 Mixed Episode

• Criteria for both manic and major depressive

episodes are met nearly everyday for at least
one week.
 Major Depressive Disorder
• MDD, single episode: single major depressive episode
and there has never been a manic, mixed, or hypomanic
episode

• MDD, recurrent episode: there have been two or more

major depressive episodes at least two months apart and
there has never been a manic, mixed, or hypomanic
episodes

• Dysthymic disorder: a depressed mood that lasts most of

the day for a majority of days over at least two years
DYSTHYMIC DISORDER
• During the period of symptoms, the person should not
have been symptom-free for more than two months at
a time and he or she should have experienced no
major depressive, manic, mixed, or hypomanic
episode or cyclothymic disorder

• There must be at least two of the following symptoms:

1) Poor appetite or overeating
2) Insomnia or too much sleeping
3) Fatigue
4) Low self-esteem
5) Poor concentration or difficulty with decisions
6) hopelessness
Bipolar Disorders
• Various bipolar disorders are distinguished by
the presence of either a manic episode or a major
depressive episode

• They are classified as either bipolar I or bipolar

II depending on which is the dominant mood.

• Bipolar I features a dominant manic mood

• Bipolar II features a dominant depressive mood

Bipolar I

• Bipolar I, single manic episode

• Bipolar I, most recent episode hypomanic
• Bipolar I, most recent episode manic
• Bipolar I, most recent episode mixed
• Bipolar I, most recent episode depressed
Bipolar II
• There is one or more major depressive episodes
and at least one hypomanic episode in the past,
but there has never been a manic or mixed
episode
Cyclothymic Disorder
• There have been periods of hypomanic
symptoms with periods of depressive symptoms
for at least two years and the person has not
been symptom free for more than two months

• There has been no major depressive, manic, or

mixed episode during that time.
 Epidemiology
• Major depression is twice as common in females as in males

• Depressive disorders affect 1 in 5 women and 1 in 10 men (gender-

related stressors, hormones, endocrine system involvement)

• Bipolar disorders: men=women

• Major depression is 1.5 to 3 times more common among relatives

of people with the disorder

• 5% of the population have bipolar disorder

 Etiology
• Causes of mood disorders are unknown
• Physical diseases such as Addison’s and Cushing’s
disease, thyroid disorders, diabetes, syphilis,
multiple sclerosis, and chronic brain syndromes
related to arteriosclerosis may induce depression
• Other disorders associated with depression:
mononucleosis, anemia, malignancies,
hypoglycemia, colitis, CHF, RA, asthma
• Medications associated with depression:
antiparkinsonian agents, hormones, steroids,
antihypertensives
 Pathophysiology
There are multiple factors involved in mood disorders:
• Biochemical
• Neuroendocrine
• Genetic
• Socio-environmental
• Psychosocial
• Psychophysiological

Quiz: ¼ sheet of paper, summarize the

etiologic theories; 15 minutes
 Course and Prognosis
• The average age of onset of bipolar disorder in the US is 20 years for
men and 25 years for women

• Average age of onset for major depression is between 30-35

• Recurrence is typical of mood disorders.

• Suicide is the main, but not the sole, cause of this elevated mortality.

• Other over-represented causes of death among patients with mood

disorders are accidents, cardiovascular disorders, cerebrovascular
disorders, respiratory infections, thyroid disorders, and secondary
substance abuse/dependence.
 Diagnosis and Evaluation
• DSM-IV

• Observation, history, interview

• Life events inventory

• Beck Depression Inventory

• Hamilton Rating Scale for Depression

 Management
• Psychotherapy and medications

• Mood stabilizers for Bipolar disorder: Lithium

and anticonvulsants (carbamazepine and
valproate)

• Antipsychotics (clozapine) are used for acute

manic episodes
 Management

• Optimal medicines for major depression: SSRIs and

tricyclic medicines (Zoloft, Prozac, etc), MAOIs

• Electroconvulsive Therapy

• Cognitive-Behavioral Therapy (CBT) and

Interpersonal Therapy (IPT) are the most effective
psychotherapy treatments for depression
particularly for acute episodes; 4-20 sessions
 Management
• Family therapy aids in maintaining support for the
individual in the environment

• Behavioral therapy for depressive disorders is designed to

alter behaviors that may be keeping a person isolated or
feeling defeated.

• Cognitive therapy is the designed to change negative

thinking processes that contribute to depression. Distorted
thinking is targeted, and the here-and-now therapy
interactions and current life situations are the focus for
changing thinking.
 Management
• Peer-Support interventions

• Family Focused Therapy (FFT)

• Interpersonal Social Rhythm Therapy (IPSRT)

• Biological approach

• Psychoanalytic theories attempt to change

personality structure; transference
Occupational Therapy Evaluation and
Intervention
Functional Consequences of Depression
• Insufficient drive, low self-esteem and negative
self-talk may lead to poor self-care, an unkempt
appearance and a disorganised, untidy or dirty
environment at home and at work.

• The ‘sick role’ may be used for secondary gain.

Avoidance of responsibilities may place strain on
interpersonal relationships
Functional Consequences of Depression
• Apathy may lead to poor productivity that in turn
may reinforce a low self-esteem, setting up a vicious
cycle of poor occupational performance

• The lack of motivation or a lack of pleasure when

engaging in the activities may lead to occupational
imbalance or deprivation, for example, avoiding
social situations

• Masked depression may present as occupational

imbalance, for example ‘Workaholic’ behaviour
 Functional Consequences of Mania
• Too busy and preoccupied to care about taking a bath,
washing hair or eating

• Grooming is overdone, makeup is thickly applied,

flamboyant clothing (bright colours, lots of jewellery)

• Increased creativity during hypomanic period. High

quantity of productivity, sometimes poor quality –
starts many projects but seldom completes any due to
flight of ideas and poor concentration
 Functional Consequences Of Mania
• Starts projects or makes promises impulsively with
little foresight into feasibility or long-term implications.

• Unable to identify and respond to social cues.

Expansive and intrusive interpersonal relationships
create tension in social contexts. Overfamiliar with
strangers

• Impulsivity leading to occupational overload and

imbalance, for example, shopping sprees, excessive
drinking, reckless driving, indiscriminate sexual
encounters
 Roles of the OT
• Evaluate a person’s ability to work and take care
of himself or herself.

• Identify treatment goals that are meaningful to the

person, such as:
▫ establishing a personal care routine
▫ managing money
▫ communicating effectively with family, caregivers,
and co-workers
▫ setting realistic short-term and long-term goals.
 Roles of the OT
• Adapt activities and the environment so that the
person can participate in tasks that are meaningful
to them.

• Monitor a person’s response to medication used to

treat a mood disorder.

• Educate family members and caregivers about

mood disorders, and collaborate with them on
treatment goals.
 OT ASSESSMENT
The aims of assessment are to:

• Identify the type and severity of performance

component impairments

• Determine the impact of the illness process on

occupational performance

• Identify the barriers and facilitators for

participation in the person’s lived environments.
 OT ASSESSMENT
• Interview
• Beck Depression Inventory
• Hamilton Depression Inventory
• Occupational Performance History Interview
(OPHI-2)
• Canadian Occupational Performance Measure
(COPM)
• Occupational Self-Assessment
 OT INTERVENTIONS
• Occupational therapy will guide the person towards
occupations that affirm self-esteem and enable
emotions to be expressed in ways that promote a
positive sense of identity, purpose and belonging.
 Approaches to the patient in the initial
phase of depression:

• Speak slowly and what the patient can understand

allowing time for him to react.
• Limit content of speech to points on which patient
must focus.
• Focus patient’s attention by saying his/her name.
• Move slowly.
1) Occupational Therapy Activities 
2) Promote initiation or participation
Together with the individual therapist, identify the
reasons for lack of participation, e.g. attention
deficits, embarrassment, and depression.

3) Motivational hints individuals are more likely

to participate in activities that address issues that are
of interest or concern to them. The more ownership
patients have in the activity, the more they will
participate. Success, fun, positive feedback and
rewards are motivating things.
4) Group therapy

• Life skills groups

• Psycho-education groups
• Support groups
• Creative activity groups
5) Cognitive Behavioral Therapy (CBT)
1. Accepting your diagnosis.
2. Monitoring your mood. 
3. Undergoing cognitive restructuring. 
4. Problem-solving frequently. 
5. Enhancing your social skills. 
6. Stabilizing your routine.
6) Improve Self Esteem
Creative, functional, occupational, and
pleasurable activities can be planned by the
therapist to boost the self esteem and self
importance.
• Interventions for Depression (Table 8-3)
• Interventions for Mania (Table 8-4)

Indecision and ambivalence = Engage in group activities,

Initially provide occupations and do not require too many choices.

Worthlessness and guilt = Engage in activities that focus on

self-exploration, such as recognizing and dealing with emotions,
self-expression, and self-exploration through creative media and
expanding coping styles.

Increased energy resulting in distractibility = Assist client

to return to goal-directed action whenever distracted. Eventually
assist in goal setting and planning and in anticipating the
consequences of actions by monitoring behavior during activities.