Major Depressive Disorder and Bipolar Mood Disorders
- Karen Kyeunghae LeeKaren Kyeunghae LeeSchool of Social Welfare, University of Kansas
Depression and bipolar mood disorders are mental disorders that are characterized by mood disturbance combined with decreased functioning of the affected individuals. This entry focuses on major depressive disorder and bipolar I and II disorders among adults in the United States. Bipolar disorder has unique clinical features and intervention options, and so it is discussed in a separate section after depression. Diagnosis, prevalence, comorbidity, risk factors, course, assessment, treatment, service utilization, and international perspectives are reviewed for each disorder. The implications for social work are briefly addressed at the end of this entry.
Major Depressive Disorder
The term depression frequently refers to low mood states ranging from feeling down to clinical disorders known as depressive disorders. Depressive disorders adversely affect important aspects of one’s life, such as interpersonal relationships, employment, and legal matters. Depression also burdens the economy: The annual economic cost of depression, which includes medical expenses, loss of productivity and other associated costs, exceeds $70 billion in the United States (Greenberg, Stiglin, Finkelstein, and Berndt, 1993; Philip, Gregory, and Ronald, 2003).
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), which provides a base for diagnosis of mental disorders in the United States, depression is actually diagnosed as eight disorders: disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depression disorder, depressive disorder due to another condition, other specified depressive disorder, and unspecified depressive disorder. While depressive disorders share common characteristics of depressed mood, and physical and cognitive changes that significantly impact an individual’s functioning, they differ in terms of duration, timing, or assumed etiology. This entry will address issues related to major depressive disorder. Complete descriptions for other depressive disorders, including their full diagnostic criteria, are available in DSM-5 (APA, 2013).
The central feature of a major depressive disorder (MDD) is either depressed mood or loss of interest or pleasure in usual activities that persists at least two weeks. An individual is diagnosed as experiencing MDD in the presence of five or more of the following nine symptoms: persistent sadness, inability to experience pleasure, changes in sleep and appetite, psychomotor agitation or retardation, feelings of worthlessness and or guilt, difficulty with concentration and making decisions, loss of energy, and thoughts of death. These symptoms must be present nearly every day, represent a change from the individual’s usual self, and cause clinically significant distress or impairment in social, occupational, or other areas of life. In addition, the symptoms cannot be attributable to other conditions, such as substance abuse or general medical conditions.
DSM-5 details changes in depressive disorders from the previous version of the DSM. Disruptive mood dysregulation disorder for children under eighteen years of age is newly included for diagnosing children who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Premenstrual dysphoric disorder was moved from the section “Criteria Sets and Axes Provided for Further Study” in DSM-IV. Dysthymia is now categorized as a persistent depressive disorder. While bereavement (depressive symptoms lasting less than two months following the death of a loved one) was placed in the above exclusion criteria in DSM-IV (APA, 2000), it was removed from DSM-5. This change was made because MDD typically occurs in the context of a psychosocial stressor, which includes bereavement.
In addition to the DSM classification system, the International Classification of Diseases (ICD) is used as an official coding system for billing health management and diagnostically for monitoring the incidence and prevalence of disease and other health problems in the United States. DSM-5 provides the current and forthcoming ICD codes in the text and appendix (APA, 2013). The implementation of the latest version of the ICD (ICD-10-CM) is scheduled for October 1, 2015 (Moran, 2014); providers continue to use the ICD-9-CM for billing and may use either DSM-IV-TR or DSM-5 criteria for diagnosis and treatment until that date (Regier and Narrow, 2014). The latest news and information on ICD-10-CM is available via the websites of the American Psychiatric Association (http://www.dsm5.org) and Centers for Medicare and Medicaid Services (http://www.cms.gov/Medicare/Coding/ICD10/index.html).
The lifetime prevalence of MDD among U.S. adults is estimated as 16.2% (Kessler et al., 2003). The same study reports that MDD affects 6.6% of adults in a given year, and 38% of these cases (2.0% of U.S. adults) are classified as severe and 12.9% as very severe (Kessler et al., 2003). A number of demographic factors reported to be associated with an increased prevalence of MDD during one’s lifetime include being female, middle-aged, never or previously married, having a low income, being unemployed, or having a disability. Women are 63% more likely than men to experience depression during their lifetime. Non-Hispanic Blacks were found to be 38% less likely than non-Hispanic Whites to experience depression during their lifetime (Kessler et al., 2003).
A recent study also shows a similar twelve-month prevalence rate. According to the National Survey on Drug Use and Health (NSDUH), the twelve-month prevalence rate of major depressive episode in 2012 was 6.9%, or 16 million community-residing adults (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). Consistent with other data, the past year rate of major depressive episode was higher for women than men (8.4% versus 5.2%) and showed similar ethnic variations: American Indian or Alaska Native (10%), two or more racial groups (7.7%), White (7.1%), Hispanic (7.0), Black (6.3%), Asian (3.2%). Among those adults who had a major depressive episode in the past year, 10.9 million individuals (68.0%) received treatment (e.g., medication, counseling) for depression within the year. The National Institute of Mental Health (NIMH) provides updates on mental health statistics regularly at http://www.nimh.nih.gov/statistics/index.shtml.
Depression may coexist with other mental or physical disorders and this co-occurrence has an adverse impact on the course of the depression. Among those who reported experiencing MDD during their lifetime, 72.1% reported having other DSM-IV disorders: 59.2% reported having an anxiety disorder, 24.0% had a substance use disorder, and 30.0% reported impulse control disorders (Kessler et al., 2005). Other psychiatric disorders, such as panic disorder, obsessive-compulsive disorder, eating disorders, and borderline personality disorder frequently co-occur with MDD (APA, 2013).
Among people with physical health conditions, there is a greater prevalence of MDD than in the general population. Some medical conditions are known to directly cause mood symptoms (e.g., stroke, hypothyroidism) while others tend to act as ongoing stressors, making individuals vulnerable to depression. Common physical illnesses known to be associated with depression include stroke, hypertension, heart disease, diabetes, cancer, and osteoarthritis (APA, 2010).
It is commonly believed that the combination of genetic, biological, environmental, and temperamental factors largely determine vulnerability to depression. Major psychosocial stressors include bereavement, culture and ethnicity, older age, gender, pregnancy and postpartum, and family history. First degree family members of individuals with MDD are two to four times more likely to develop MDD than individuals without a family history (APA, 2013). Adverse childhood experiences are potential risks for developing depression.
Although MDD can develop at any age, the likelihood of onset increases with puberty and seems to reach its peak in individuals in their twenties (APA, 2013). The course of MDD varies across individuals in terms of having or not having symptom free periods (remission) between depressive episodes. While most individuals with MDD experience recovery within one year of onset, the following factors are associated with lower recovery rates: having psychotic symptoms, prominent anxiety, personality disorders, and severe depressive symptoms. The risk of recurrence tends to become lower over time as the duration of remission increases. However, the risk of recurrence is higher for individuals with previous multiple episodes, severe symptoms, mild depressive symptoms during remission, and those who are young (APA, 2013).
A number of instruments are available to assess the presence and severity of depressive symptoms. They are often used for the purpose of screening, diagnosing, and monitoring treatment outcomes as well as for research. There are two formats of instruments: standardized rating scales or semi-structured interview format. Some of the standardized rating scales based on self-reports include the Center for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977), Beck Depression Inventory (BDI, Beck and Beck, 1972; BDI-II, Beck, Steer, and Brown, 1996), and the Patient Health Questionnaire—9 (PHQ-9, Kroenke and Spitzer, 2002). One of the most commonly used semi-structured interviews is the Structured Clinical interview for DSM-IV Axis I Disorders (SCID), which inquires about current and past symptoms (see more information on http://www.scid4.org). Another tool, the Composite International Diagnostic Interview (CIDI), also assesses MDD as defined by DSM-IV and International Classification of Diseases (ICD-10). This diagnostic interview, developed by the World Health Organization (WHO) to be administered by non-clinicians (see Kessler and Üstün, 2004 for more information) has been used widely in epidemiological studies (Kessler et al., 2003). Another clinician-interview instrument includes the Hamilton Rating Scale for Depression (HAM-D, Hamilton, 1960). Most psychiatric rating scales for depression are available at http://www.neurotransmitter.net/depressionscales.html.
The two main treatment modalities for depression are pharmacological treatment and psychosocial intervention. Selection of intervention is influenced by severity and chronicity of symptoms, any coexisting conditions and ongoing stressors, as well as preferences of individuals receiving services. Psychosocial interventions are often recommended as first-line treatments in mild cases. However, a combination of pharmacological and psychosocial intervention has been considered as the best practice for moderate to severe depression treatment (APA, 2010; de Maat, Dekker, Schoevers, and Jonghe, 2007).
There are three major classes of antidepressants in the United States: tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake inhibitors (SSRIs). The antidepressants work on neurotransmitters, such as norepinephrine, serotonin, and dopamine (APA, 2010). TCAs, such as imipramine (Tofranil) and amitriptyline (Elavil), were the standard treatment for depression before the introduction of SSRIs. TCAs work by blocking reuptake of serotonin and norepinephrine in the brain. While many studies showed that TCAs are as effective as SSRIs in treatment of depression, in a meta-analysis TCAs were found to be more effective than SSRIs in treatment of inpatient adults with depression (Anderson, 2000). The same study reported less tolerability of TCAs compared to SSRIs due to negative side effects such as dry mouth, constipation, bladder problems, sexual problems, blurred vision, and drowsiness. TCAs are one of the common medications taken in self-poisoning and are highly lethal in medication overdoses (Kerr, McGuffie, and Wilkie, 2001). MAOIs are the oldest class of antidepressants and can be effective for some people. However, due to potential health risks caused from interaction of this drug with food and other drugs, people taking MAOIs need to be monitored closely by doctors (APA, 2010). The SSRIs are the most commonly used antidepressants, and they include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), and escitalopram (Lexapro). Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor) and duloxetine (Cymbalta). Bupropion (Wellbutrin) is another antidepressant that is commonly used and it works on dopamine. SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants (Anderson, 2000). Some of the common side effects of SSRIs and SNRIs are headache, nausea, sleep disturbance, agitation, and sexual problems.
While medications have been largely considered as the first line of treatment for people with moderate to severe depression, recent studies have raised questions about the effectiveness of antidepressants, especially the SSRIs. A study reviewing all clinical trials submitted to the U.S. Food and Drug Administration (FDA), including unpublished studies, reported that the efficacy of the SSRIs depended on the severity of initial depression, and the difference between SSRIs and placebo was evident only for people in the very severely depressed group (Kirsch et al., 2008). Another meta-analytic study reported that the effect of the antidepressant did not significantly differ from placebo for mild or moderate symptoms of depression (Fournier et al., 2010). Generalizing findings from the study by Fournier and his colleagues to the efficacy of all SSRIs might be difficult due to the small number of studies reviewed (six studies) and the inclusion of only one SSRI (three studies with paroxetine) and one TCA (three studies with imipramine). Research and development of new antidepressants continues at a rapid pace and so it is vital that social workers keep up with the latest findings. More information on medication is available at http://www.nimh.nih.gov/health/publications/mental-health-medications/index.shtml, and the latest information on antidepressants is available on the FDA website (http://www.fda.gov/Drugs/).
Psychosocial interventions have been demonstrated to be effective in depression treatment. Overall, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are considered as evidence-based interventions for MDD, and several interventions show promise, such as psychodynamic psychotherapy, problem-solving therapy, marital and family therapy, and group therapy.
Cognitive behavioral approaches emphasize the role of a person’s thoughts on emotional and behavioral responses to life events (Beck, 1976; Ellis, 1994). Based on the seminal work of Aaron Beck (see resources and training information from the Beck Institute for Cognitive Behavior Therapy at http://www.beckinstitute.org), cognitive behavior therapy (CBT) helps individuals with depression reframe negative views of self, environment, and the future in a positive and realistic way (APA, 2010). Studies have shown that CBT is particularly effective for treating mild or moderate depression. CBT has been extensively studied in controlled trials and the efficacy of CBT has been examined in many studies, including meta-analyses. When CBT is compared to no or minimal treatment, its effectiveness has been robust and fairly consistent (Blackburn and Moore, 1997; Dobson, 1989; Gaffan, Tsaousis, and Kemp-Wheeler, 1995; Gloaguen, Cottraux, Cucherat, and Blackburn, 1998). Evidence also shows that the effectiveness of CBT is comparable to medication in acute treatment of depressed outpatients in terms of rates of response and remission in individuals with moderate to severe MDD (DeRubeis et al., 2005; Hollon et al., 2005; Honyashiki et al., 2014; Jarrett et al., 1999). Unlike medication, it appears to have long-lasting effects: Some studies have shown that CBT decreases the risk of relapse even after the treatment is terminated (Hollon et al., 2005) and continuing CBT in a maintenance phase further decreases this risk (Bockting et al., 2005; Paykel et al., 1999). However, the effectiveness of CBT has also been shown as comparable to other short-term psychotherapies such as IPT and brief dynamic psychotherapy (Jakobsen, Hansen, Simonsen, Simonsen, and Gluud, 2012; Jarrett and Rush, 1994). Several CBT manuals for treatment of depression have been published and the information is available at the following website: https://hss.semel.ucla.edu/Resources/CBT.html.
Interpersonal therapy (IPT) is based on the notion that life events influence the onset and expression of depression. The main goal of IPT is to help individuals better understand and cope with depression by making connections between current life events and the onset of symptoms. This is achieved, in part, by helping individuals to overcome interpersonal problems in an effort to improve life circumstances and relieve depression. Its focus is on current events and relationships rather than on past relationships or problems (Klerman, Weissman, Rounsaville, and Chevron, 1984; Weissman, Markowitz, and Klerman, 2000). In general, IPT is superior to treatment as usual and is an effective augmentation strategy for people receiving pharmacotherapy. A meta-analysis of thirteen studies of IPT conducted from 1974 to 2002 reported that, in nine of the studies, IPT was superior to placebo and more efficacious than CBT (de Mello, de Jesus Mari, Bacaltchuk, Verdeli, and Neugebauer, 2005). Another meta-analysis study reported that IPT is as effective as CBT (Jakobsen et al., 2012; Parker, 2007). Several IPT manuals for treatment of depression have been published and the information is available at the following website: http://interpersonalpsychotherapy.org/about-ipt
Along with pharmacological and psychosocial interventions for depression treatment, increased attention has been paid to other approaches, including complementary and alternative medicine, physical exercise, and brain stimulation therapies. Complementary treatment is used with conventional treatment, while an alternative treatment is used in place of a conventional treatment. Some of the widely used complementary and alternative treatments include St. John’s wort, light therapy, acupuncture, omega-3 fatty acid, and folate. However, evidence is largely lacking in using those treatments alone for depression treatment (APA, 2010). Also, potential interaction between complementary/alternative treatments and prescription medication has been reported (APA, 2010). Many studies have reported the beneficial effect of physical exercise on depression (Mura, Sancassiani, Machado, and Carta, 2014; Singh, Clements, and Singh, 2001). While exercise seems to improve depressive symptoms compared with no treatment or control intervention, the effect in favor of exercise decreases when only methodologically robust trials are included (Rimer et al., 2012). Considering the lack of evidence using physical exercise as a sole treatment for depression, combined use of physical exercise with conventional interventions may be the approach to take in reducing depression symptoms (Mura, Sancassiani, Machado, and Cartal, 2014).
Brain stimulation therapies to treat depression involve activating the brain directly with electricity, magnets, or implants. Among these brain stimulation therapies, electroconvulsive therapy (ECT) has been used the longest and researched the most. ECT is usually considered as a treatment option for individuals with severe depression or those who are in life threatening situations due to suicidality or severe malnutrition (APA, 2010). The efficacy of ECT in the treatment of depression has been shown via a high remission rate for people with severe MDD (Kellner et al., 2006) and also through reducing the relapse rate with follow-up treatment (Fink and Taylor, 2007). Other types of brain stimulation therapies have been introduced recently to treat severe depression, including vagus nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS). A few studies have suggested that VNS show promise in treatment-resistant depression (Aaronson et al., 2013; George et al., 2005). However, these methods are still experimental in nature (George and Aston-Jones, 2010), and the effects on depression are not established.
Special Considerations for Treatment
Special attention is required in treating depression, particularly concerning the issues of suicidality, depression during pregnancy and postpartum, and depression in older adults. Risk factors for completed suicide include being male, being single or living alone, and having prominent feelings of hopelessness. The comorbidity with borderline personality disorder significantly increases risk for future suicide attempts (APA, 2013). The Columbia-suicide severity rating scale (C-SSRS) has standardized questions to assess varying levels of suicidal ideations to suicidal behaviors, and it can be administered in both psychiatric and non-psychiatric settings by either clinicians or others with brief training. Different versions of the scales and training information are available at the following website: http://www.cssrs.columbia.edu/index.html.
Postpartum depression affects 10% to 15% of women and it remains underdiagnosed and undertreated (Kessler et al., 2003). Risk factors for depression during pregnancy and postpartum include a history of anxiety, mood or eating disorders, a depression during a previous pregnancy, and increased life stressors (Josefsson et al., 2002; O’hara and Swain, 1996). While depression is less prevalent among older adults than among young age groups (Hasin, Goodwin, Stinson, and Grant, 2005), it is often missed or untreated, resulting in devastating consequences (Blazer, 2003). The presentation of symptoms, etiology, risk, and protective factors and potential outcomes of depression in older adults differs from symptoms found earlier in the lifespan, requiring knowledge and consideration of age in the assessment and treatment of older adults with depression (Fiske, Wetherell, and Gatz, 2009).
While advances have been made in treatment guidelines and increased outreach efforts, a majority of people with depression still remain untreated or undertreated (Kessler et al., 2003; Young, Klap, Sherbourne, and Wells, 2001). Approximately 51% who experienced MDD in the past year received treatment for MDD, although treatment was considered adequate in only 21% of the cases (Kessler et al., 2003). Members of ethnic and racial minority communities are far less likely than others to be treated (U.S. Department of Health and Human Services, 2001). Among adults who have experienced depression in the past twelve month, all ethnic and racial minority groups reported significantly lower mental health service use, compared with non-Latino Whites (59.8%): 31.3% of Asian Americans, 36.3% of Latinos, and 41.2% of African Americans (Alegria et al., 2008).
Reducing racial and ethnic disparities in access to, and quality of, mental health care remains a key challenge of the mental health system. To improve the early detection of symptoms, access to formal mental health services, and quality of mental health services, various innovative interventions have been suggested and implemented. Those programs include collaborative care models implemented for Hispanics (Ell et al., 2009; Ell et al., 2010) and collaborative treatment models implemented in primary care (Kwong, Chung, Cheal, Chou, and Chen, 2013; Yeung, Shyu, Fisher, Wu, Yang, and Fava, 2010). Recent meta-analysis of depression treatment for racial and ethnic minority older adults showed that collaborative or integrated care shows promise for African Americans and Latinos (Fuentes and Aranda, 2012). In addition, collaboration between mental health agencies and faith-based communities has been frequently recommended (Taylor, Ellison, Chatters, Levin, and Lincoln, 2000; Yamada, Lee, and Kim, 2011).
International Perspectives on Depression
Depression is a significant public health issue across the world. Depression is a leading cause of disability worldwide, as 350 million people are estimated to have some forms of depression (World Health Organization, 2012), and it is strongly believed to be related to conditions found in the society. A study that reviewed international epidemiological data for 18 countries on depression (Bromet et al., 2011) reported that more MDE has been reported in 10 high-income countries (15% of the population in a lifetime) compared to middle/low-income countries (11%). However, many similarities across different countries exist in several aspects of MDD. For example, women were two times more likely to have MDE and several sociodemographic factors were consistently associated with adverse outcomes: Difficulties in role transitions were associated with low education, high teen pregnancy, martial disruption, and unstable employment; reduced role functioning was found with low marital quality, low work performance, and low earnings. In addition, elevated risk of onset, persistence, and severity of a wide range of secondary disorders as well as increased risk of early mortality due to physical disorders and suicide were reported among people with MDD (Kessler and Bromet, 2013).
Despite some of these similarities, differences in working with affected individuals from different cultures may stem from the cultural explanation for the illness (for example, definition, cause) and the behaviors associated with it, such as coping and seeking help (APA, 2013). The DSM-5 includes cultural variations in its description and a Cultural Formulation Interview (CFI) that clinicians can use to better understand an individual’s understanding of his or her own problem and solution for it (APA, 2013).
Bipolar disorder (BPD) is a serious mental illness and often results in high direct and indirect costs (Kleinman et al., 2003). The annual direct and indirect costs for treating bipolar disorder in 2009 were estimated to reach $151 billion in the United States alone (Dilsaver, 2011). Bipolar disorder is a leading cause of premature mortality due to suicide and associated medical conditions, such as diabetes mellitus and cardiovascular disease (Kupfer, 2005; Osby, Brandt, Correia, Ekbom, and Sparen, 2001). Also, bipolar disorder causes widespread role impairment (Calabrese et al., 2003; Dean, Gerner, and Gerner, 2004). The individuals with BPD are more likely to be non-employed, and to have more social, cognitive, and work limitations, compared to individuals with depressive disorders (Shippee et al., 2011).
According to the DSM-5 (APA, 2013), bipolar and related disorders include bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance/medication-induced bipolar and related disorder, bipolar and related disorder due to another medical condition, other specified bipolar and related disorder, and unspecified bipolar and related disorder. This entry addresses issues related to bipolar I disorder and bipolar II disorder. Complete descriptions for other bipolar and related disorders, including their full diagnostic criteria, are available in DSM-5 (APA, 2013).
For an individual to be diagnosed with bipolar I disorder, he or she must meet the criteria for at least one manic episode. While hypomanic episodes or major depressive episodes (MDE) are common in bipolar disorder, they are not required for the diagnosis of bipolar I disorder. The central feature of a manic episode is a profound and persistent mood disturbance characterized by elation, irritability, or expansiveness and increased activity or energy that lasts at least one week. Three or more of the following seven symptoms are present during the episode: Grandiosity, diminished need for sleep, excessive talking or pressured speech, racing thoughts or flight of ideas, clear evidence of distractibility, increased level of goal-focused activity or psychomotor agitation, or sexually, excessive pleasurable activities, often with painful consequences. These symptoms are severe enough to cause impairment in social and work functioning, lead to hospitalization, or are presented as combined with psychotic features. The manic episode is assessed as part of the mental illness, and it must not be attributable to the effect of substances or other medical condition (APA, 2013).
Bipolar II disorder requires at least one episode of major depression disorder and at least one hypomanic episode during one’s lifetime. If a person ever had a manic episode, this person must be diagnosed with bipolar I disorder. To meet the criteria for a hypomanic episode, the same symptoms must be present but with a shorter duration (at least four consecutive days instead of one week as required in a manic episode), and with less severe impairment in social or occupational functioning. The diagnostic criteria for a MDD are listed in the depression section of this entry. Bipolar II disorder is no longer considered a condition milder than bipolar I disorder, mainly due to the extended amount of time people suffer from depression and serious impairment in social and occupational functioning (APA, 2013).
Bipolar disorder was considered to be a mood disorder in the DSM-IV. In the DSM-5, bipolar and related disorders are separated from mood disorders and placed between schizophrenia spectrum disorders and depressive disorders. This change reflects the observation that individuals with bipolar disorder often experience psychotic symptoms, and recent evidence from genetic and family studies shows shared vulnerabilities for these disorders (APA, 2013).
Although people may also present with symptoms of mania, more people present with symptoms of a major depressive episode when they initially seek treatment. Studies report that approximately 40% of individuals with bipolar disorder are initially misdiagnosed with unipolar depression (Ghaemi, Boiman, and Goodwin, 2000), which delays the initiation of specific bipolar treatment (Beesdo et al., 2009; Perlis et al., 2004). Therefore, inquiring about the history of manic or hypomanic episode is critical to assure a correct diagnosis and treatment planning (Bowden, 2001).
Bipolar disorder affects approximately 9 million adults, or 4.4% of U.S. adults in their lifetime: 1.0% for bipolar I disorder,1.1% for bipolar II disorder, and 2.4% for subthreshold bipolar disorder (Kessler, Merikangas, and Wang, 2007). The same study reports that bipolar disorder affects approximately 2.8% of U.S. adults, equivalent to more than 5 million U.S. adults in a given year: 0.6% for bipolar I disorder, 0.8% for bipolar II disorder, and 1.4% for subthreshold bipolar disorder. Bipolar disorder is inversely related to age and educational level and to the unemployed-disabled compared to the employed. Bipolar disorder is unrelated to sex, race/ethnicity, and family income. Sex-specific (male and female) prevalence estimates are 0.8% and 1.1% for bipolar I disorder, 0.9% and 1.3% for bipolar II disorder (Merikangas et al., 2007).
Bipolar disorder is associated with high rates of psychiatric, substance, and medical illnesses. Over 70% of persons with bipolar disorder met criteria for at least one other mental disorder in their lifetime (Merikangas et al., 2011). More specifically, 63.1% to 86.7% of respondents with lifetime bipolar disorder also met criteria for at least one lifetime comorbid anxiety disorder and 35.5% to 60.3% met criteria for at least one lifetime comorbid substance use disorder (Merinkangas et al., 2007). High rates of medical comorbidity have been reported, including hypertension, diabetes, pulmonary disease, hepatitis C, and other conditions, especially among veterans with bipolar disorder (Kilbourne et al., 2004). Comorbidity affects evaluation, course, and treatment of the affected individuals and also affects social and economic costs (Merikangas and Kalaydjian, 2007). A higher number of medical comorbidity was associated with a longer duration of lifetime depression and lifetime inpatient depression treatment, severe depression symptoms, and higher service utilization for depressive episode and increased suicidal behavior among individuals with bipolar disorder (Thompson, Kupfer, Fagiolini, Scott, and Frank, 2006).
It is commonly believed that the combination of genetic, biological, and environmental factors largely determine vulnerability to bipolar disorder. Marital disruption (separation, divorce, or widowed) is associated with higher rates of bipolar I disorder. On average, adult relatives of individuals with bipolar I and bipolar II disorder are ten times more likely to develop the illness as are individuals without a family history (APA, 2013).
The age of onset of bipolar disorder usually falls between 15 and 24 years (Bauer et al., 2010; Perlis et al., 2004): bipolar I disorder (18.2 years) and bipolar II disorder (20.3 years) (Merikangas et al., 2007). The effect of depressive episodes in individuals with bipolar disorder, in terms of duration of episodes and quality of life, is considerably worse than the effect of manic episodes (Calabrese, Hirschfeld, Frye, and Reed, 2004; Judd et al., 2002). The vast majority of people who have one manic episode tend to experience a recurrent mode episode. More than half of manic episodes occur immediately before a MDE. Individuals who have four or more mood episodes in any one year receive a “with rapid cycling” specifier (APA, 2013).
One of the widely used assessment tools for bipolar disorders is the Structured Clinical Interview for DSM-IV (SCID). However, the SCID has been found to have limitations for diagnosing bipolar disorder, especially bipolar II disorder (Benazzi and Akiskal, 2009). The three main screening tools used for bipolar disorder are the Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000), Hypomania Checklist (HCL-32; Angst et al., 2005), and Bipolar Spectrum Diagnostic Scale (BSDS; Phelps and Ghaemi, 2006). These tools have been employed in a number of recent cross-sectional studies to examine the level of undetected bipolar spectrum disorders. However, currently no single screening tool is reliable enough to be used alone for the purpose of diagnosis. Therefore, assessment by a mental health specialist or additional information on the history of past episodes is necessary to confirm the diagnosis.
With medication, psychotherapy, or combined treatment, most people with bipolar disorders can be effectively treated and resume productive lives.
Bipolar disorder is treated with medication and treatment depends on the presenting phase of illness (for example, mania, hypomania, MDE, mixed state, or maintenance) and its severity. For acute manic episode, lithium, some anticonvulsants (e.g., valproate, carbamazepine), and several atypical antipsychotics (for example, aripiprazole, haloperidol, olanzapine, quetiapine, risperidone) are used either by themselves or as a combination (Grunze et al., 2009; Hirschfeld, 2005; Yatham et al., 2009). For depressive episode in bipolar I disorder, evidence shows that olanzapine-fluoxetine combination, quetiapine, and lamotrigine are most effective. While combined use of antidepressants and mood stabilizers has modest effects, use of antidepressants without a mood stabilizer is not recommended (Hirschfeld, 2005).
Some psychosocial interventions have shown effectiveness when used with pharmacotherapy. Family-focused therapy (FFT) is a manualized psychosocial program, involving all available family members in weekly psychoeducation, communication enhancement training, and problem-solving skills training. Several studies have found FFT to be effective in helping a patient become stabilized and preventing relapses (Miklowitz et al., 2007; Miklowitz, George, Richards, Simoneau, and Suddath, 2003; Rea et al., 2003). Cognitive Behavioral Therapy (CBT) can help a person cope with bipolar symptoms and learn to recognize when a mood shift is about to occur. A systematic review and meta-analysis of randomized or quasi-randomized controlled trials reported that CBT may be effective for relapse prevention in stable individuals with bipolar disorders (Beynon, Soares-Weiser, Woolacott, Duffy, and Geddes, 2008). One randomized, controlled study examined the utility of cognitive therapy in conjunction with pharmacotherapy and found significant beneficial effects of cognitive therapy in terms of fewer bipolar episodes, episode days, and number of hospital admissions over a 12-month period (Lam et al., 2003; Lam, Hayward, Watkins, Wright, and Sham, 2005). Interpersonal and social rhythm therapy (IPSRT), a variation of interpersonal therapy, focuses on addressing interpersonal problems and regulating daily routines during acute treatment in individuals with bipolar I. IPSRT combined with medications is as effective as other types of psychotherapy combined with medication in helping to extend the time to new episode and prevent a relapse of bipolar symptoms (Frank et al., 2005).
Special Considerations for Treatment
Researchers estimate the lifetime prevalence of at least one suicide attempt among individuals with bipolar disorder as between 25% and 60% and completed suicide as between 4% and 19%. One study found that the prevalence of suicide attempts was 36.3% in individuals diagnosed with bipolar I disorder and 32.4% in individuals with bipolar II disorder (Novick, Swartz, and Frank, 2010). The majority of suicides occur during the depressed or mixed mood phase of the illness. Among the best-known risk factors for suicide are having a family history of suicide, the early onset of affective symptoms, young age, a history of prior suicide attempts, and comorbidity of anxiety and substance abuse disorders (Gonda et al., 2012).
There is often a 5- to 10-year interval between onset of a bipolar disorder and receipt of treatment (Baldessarini, Tondo, and Hennen, 2003). Forty-nine percent of those with these disorders are receiving treatment, and 38.8% of those receiving treatment receive minimally adequate treatment. Lifetime treatment of emotional problems by the time of the interview was reported by 80.1% of respondents with lifetime bipolar disorder. A history of treatment for bipolar I disorder and bipolar II disorder ranges from 89.2% to 95.0%. Psychiatrists were the most common providers for bipolar I (64.9%) and bipolar II disorder (62.2%) (Wang et al., 2005).
International Perspectives on Bipolar Disorder
A World Mental Health Survey Initiative includes data from 11 countries in the Americas, Europe, Asia, the Middle East, and New Zealand and reports that prevalence rates of bipolar disorder vary considerably across studied countries: The highest prevalence rate is reported in the United States (4.4%), while India had the lowest rate (0.1%). Despite varied prevalence, some similarities exist in rates of comorbidity and underutilization of mental health services. About 75% of those with bipolar symptoms had at least one other disorder, with the majority having an anxiety disorder. Overall, less than half of those with bipolar symptoms received mental health service, but the rate of receiving services is as low as 25% in low-income countries (Merikangas et al., 2011).
According to a 2004 Global Burden of Disease study (World Health Organization, 2008), bipolar disorder was reported to be the seventh and eighth leading cause of years lived with a disability (YLD) for men and women, respectively. Similar to U.S. study results, the extent of disability and impairment is higher in bipolar disorder than in other mental disorders except for schizophrenia in Australia (Morgan, Mitchell, and Jablensky, 2005). Adults with bipolar disorder have a higher absence of working days compared to those with other mental disorders in the Netherlands (ten Have, Vollebergh, Bijl, and Nolen, 2002).
Implications for Social Work Practice
For many decades, social workers have been involved in addressing issues of depression and bipolar disorder either as members of interdisciplinary teams or as independent providers in micro, mezzo and macro levels of practice. The services typically provided by social workers include individual, group, and family therapy; case management; care coordination; and community education and advocacy. While many professionals are involved in the care of people with depression and bipolar disorder, social workers are in a unique position to care for the affected individuals, as these illnesses are influenced by the environment and may also exert influence on the environment. Social workers, as a profession, are uniquely well trained to identify environmental factors that may contribute to, trigger, or prolong the illness or relapse. These factors include unhealthy relationships; unsafe neighborhoods in inner-city areas; poverty; isolation and lack of social support in rural areas; discrimination based on race, gender, ability, etc.; and lack of availability of, or access to, community resources. When people have no means to escape such undesirable environments (due to fewer resources and less support), social workers can intervene to create more favorable environmental conditions by assessing needs and providing, or connect individuals to, resources, playing the role of case manager. At the same time, social workers can offer interventions that take into account environmental stress and empower people with depression to develop skills to systematically identify and solve their problems. In macro practice, social workers may be actively involved in efforts to change social policies and practices that may act as structural barriers to upward mobility for people with depression in poverty. Therefore the person-in-environment approach in social work is invaluable in understanding the impact of the environment on the development of depression and bipolar disorder and in providing effective treatment.
Social workers in the mental health field working directly with individuals with depression or bipolar disorder need to be aware of, and to be trained in, the latest developments in treatment as they become available, not only to benefit themselves, but also to translate the knowledge for clients and families with whom they work. Some of the emerging practice models and trends emphasize integrated health and mental health care. As integrated care becomes more of a norm, social workers need to be ready to provide services either imbedded in primary care setting or closely aligned with health professionals. Therefore, social workers need to acquire a knowledge of common physical health issues that people with mood disorders often face and skills to work collaboratively with medical providers who may or may not share the same values and beliefs in working with people with mood disorders. Another trend is using technology to provide mental health services. Telehealth uses technology to deliver mental health services to hard-to-reach populations such as home-bound older adults or people in remote locations. Social workers can make a significant impact on affected individuals as well as their family members. The majority of primary caregivers who provide direct support for those with mental illness have reported distress, as in the case of bipolar disorder (Perlick, Rosenbeck, et al., 2007). Therefore, social workers may provide necessary emotional and instrumental support as well as psychoeducation for the affected individuals and their families. Individuals suffering from recurrent episodes and their family members can benefit from learning ways to manage the illness and prevent relapse.
While social workers in mental health fields are more likely to be involved with individuals with depression or bipolar disorder or their families, social workers in other settings may also encounter individuals and their families affected by depression or bipolar disorders in settings such as schools, community centers, and agencies offering older adult services. Likewise, social workers in health-care settings may encounter people presenting physical complaints associated with depression or bipolar disorders. While their primary job responsibility may not include the treatment of depression or bipolar disorder, social workers in non-mental health settings need to have an ability to recognize symptoms, community resources for referral, and the means to advocate access to services for the affected individuals and families.
Many studies have reported stigma associated with depression and bipolar disorder and its impact on various aspects of the lives of affected individuals, including treatment seeking behavior (Interian, Martinez, Guarnaccia, Vega, and Escobar, 2007; Sirey et al., 2001). Stigma affects not only individuals with depression or bipolar disorder, but also their family members (Perlick, Miklowitz, et al., 2007). Social workers need to continue working collaboratively with affected individuals and their families to reduce self (or internalized) stigma to improve their social functioning and quality of life. At the same time, social workers may engage in ongoing work to reduce negative attitude toward mental illness in the communities. In addition, all social workers must work to reduce disparities in access to treatment, quality of care, and treatment outcomes, and they need to advocate on behalf of ethnic minorities or other underserved populations in the practice.
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