Mood

Handbook of Disabilities Mood Disorders

Mood Disorders
Also called Affective Disorders, Depressive Disorders
Description of the Disability
Mood disorders are a disturbance of the emotions, which spills over into almost every other
aspect of life. Mood disorders affect how people think, how they behave, how they care for
themselves, and their overall health. In that sense, mood disorders are total body disorders.

On the one hand, mood disorders are one of the easiest disabilities for others to relate to because
most of us have experienced something like it. On the other hand, this makes it difficult for
people to grasp how different the intensity of clinical depression is from the mild depression that
most people occasionally experience. It becomes very easy to think the person with depression
should just snap out of it or try to think about something else, but their situation is not that
simple.

Most people experiencing depression are profoundly more affected by their moods than the
average person ever is. The depression most people experience is a mild, reactive and short-term
depression – a response to some event or series of events in their life that disrupts their feelings,
but only for a little while. This type of reactive depression responds well to psychotherapy, if
needed, or to talking to a friend and waiting for the mood to pass. Clinical mood disorders are
not reactive: although they may be triggered by an event or sequence of events, they are
disproportionately intense, last for weeks or months at a time, and do not respond to talking and
other simple fixes. Mood disorders leave individuals debilitated and unable to function in basic
ways.

Along with substance abuse, mood disorders are one of the most commonly coexisting
disabilities. There are three basic types of mood disorders: Depression, Dysthymia, and Bipolar
Disorder.

Depression
(Also called Clinical Depression, Major Depression)

To be considered clinically depressed, the DSM IV requires that a person be depressed for at
least 2 weeks with symptoms present nearly every day. The central features are feeling sad or
down and not enjoying anything. The person also usually feels profoundly tired, even if they
can’t sleep. They find the smallest tasks to be too much work, including things such as dressing,
showering, and answering the phone. There is a large set of other secondary symptoms,
including:

Loss of self-esteem
Withdrawal
Feelings of helplessness or worthlessness

This document is a product of RCEP7 and the Curators of the University of Missouri 1
Updated December 5, 2001


Excessive or inappropriate guilt, sometimes almost delusional in scale
Excessive crying
Agitation (difficulty sitting still, pacing, hand wringing)
Psychomotor retardation (slowed speech, thinking, movement; long pauses before
responding; softened speech; minimal response to conversations)
Sleep disturbance (usually insomnia, sometimes excessive sleep)
Overwhelming sluggishness
Persistent daytime sleepiness
Difficulty concentrating, easily distracted
Difficulty making decisions
Change in eating habits, change in weight
Abnormal thoughts about death
Thoughts about suicide, plans to commit suicide, or suicide attempt(s)
Reduced interest in daily activities

It is important to note that, although suicide attempts are not very common, there is no way to
predict whether someone with suicidal thoughts will or will not attempt suicide. Any indication
of suicidal thoughts or plans should be passed along for attention by a therapist.

No one knows what causes depression. There is a host of theories, but none is especially
dominant. The cause is probably a combination of genetics, brain/body neurochemistry,
personality type, patterns of thought, and other factors. Effective treatment usually addresses
both psychological and medical approaches to understanding depression. In addition, effective
treatment will take time. The individual has typically spent a lifetime learning or developing the
disorder (depending on your perspective of the cause), and it takes time to alter how their
emotional system is used to functioning.

People experiencing depression usually have difficulty organizing things and making decisions.
This can impact the rehabilitation and employment processes, so it is important for VR
counselors understand this and not rush the individuals. Many VR counselors report that
individuals with mood disorders ask the counselor to make the decisions for them. They may
also have difficulty concentrating on instructions or options given to them, so counselors may
need to repeat things or confirm through conversation that the person understands what the
counselor has said.

There are several possible patterns to the depressive episodes. Some individuals have only one
episode in their life. Others have episodes many years apart or clusters of episodes with years
between the clusters. Some individuals have a pattern of increasing frequency as they grow
older. If left untreated, a major depressive episode can last between 6 months and one year. With
treatment, most episodes end within three months.



Children can also be clinically depressed, although their symptoms can be somewhat different.
They may pretend to be sick, refuse to go to school, or show separation anxiety by clinging to a
parent or worrying about what will happen if a parent dies. Older children may sulk, feel
misunderstood, get into trouble at school, and act irritable. Unfortunately, each of these
symptoms can also occur innocently as a phase of a normal childhood, making it difficult to
know if the child is actually depressed. Usually only a parent or teacher can tell when a child is
“not him self" and the difference is enough to suggest professional assessment.

Incidence Statistics for Major Depression
18.8 million adult Americans experience a depressive disorder, including depression,
dysthymia, and bipolar disorder each year
9.9 million adult American experience major depression each year
Major depression is the leading cause of disability in the US, according to the Harvard
School of Health
Women experience depression about twice as often as men, but the reasons are not clear.
There may be hormonal issues, role responsibility issues, or other causes.
Men are more likely to hide their depression than women.
Women are more likely to attempt suicide; men are 4 times more likely to succeed.
The average age of onset/diagnosis is 40, and 50% of individuals experience the first
depressive episode between the ages of 20 and 50.
50% of people experiencing a first depressive episode will have at least one more in their
life.
25% of people experiencing a first depressive episode will have a second one within 6
months.
5%-10% of people experiencing a first depressive episode will later have at least one
manic episode and which will most likely develop into recurring bipolar disorder (see
below).
10% to 15% of individuals with major depression will still experience depressive
episodes after 5 years of treatment. As the disorder progresses, the depressive episodes
tend to occur more frequently and last longer.

Dysthymia
Dysthymia is milder than major depression, but the DSM IV requires that it have lasted for at
least 2 years. Individuals with dysthymia are not as seriously debilitated as individuals with
major depression, but they are functioning at a significantly reduced level. They often describe it
as living in a constant cloud of gloom. In addition to sadness, the person may experience:

Low self-esteem
Feelings of helplessness or worthlessness



Fatigue
Sleep disturbance (usually insomnia, sometimes excessive sleep)
Difficulty concentrating, easily distracted
Difficulty making decisions
Feelings of incompetence
Reduced interest in pleasant activities

Because the mood will have lasted for so long, the person may think of these symptoms as part
of who they are and not see them as part of a disorder. In most cases, the disorder will have
developed in childhood, adolescence, or young adulthood, contributing to this sense of it being a
part of them. Alternatively, the symptoms may come and go, but always return within 2 months.
For some individuals, the dysthymia is initially triggered by stressful life event such as the loss
of a spouse, the birth of a child, or sudden unemployment.

Incidence Statistics for Dysthymia
10.9 million adult Americans experience dysthymia during their life
40% of individuals with dysthymia also experience major depression or bipolar disorder
in any given year.
Women are 2 –3 times more likely to be diagnosed with dysthymia than men

Bipolar Disorder
(also called Manic Depression, Bipolar Affective Disorder, Bipolar I Disorder)

Bipolar disorder involves an alternating sequence of depressive episodes and episodes of elation
(or “mania”) lasting at least one week. Some people with bipolar disorder experience mostly
depression with only a few manic episodes, others experience mostly mania with only a few
depressive episodes, and others an equal balance. A manic episode can start over a period of days
or even hours.

In addition to the episodes of major depression, short (but intense) “mini-depressions” can occur
during the manic episodes. This switch in mood during a manic episode can sometimes be
dramatic, changing in just a few minutes, but usually it is more gradual. The intense mini-
depressions can last hours or sometimes days, but they do not last for several weeks like major
depressions do. Individuals who move quickly between the manic and depressive moods during a
manic episode are sometimes called “rapid cyclers”. If both manic and depressive moods show
up every day for at least a week, the episode is labeled “mixed”.

In between major depressive episodes and manic episode, most individuals can function
normally. However, some people with bipolar disorder continue to show unstable moods



(“Lability of Affect”) and difficulty with social and work skills in between episodes. A few
individuals experience psychotic symptoms in between episodes.

The dominant moods of a manic episode are high-energy enthusiasm and confidence. The
individual will seem to be a bundle of energy, excited about a dozen things at one time, and full
of big plans and ideas. The DSM IV uses the term “expansive” to describe the overwhelming
confidence of people experiencing a manic episode. They will have no doubt they can succeed at
whatever they want, befriend or convince anyone they want, or acquire whatever money or
things they want. They may go up to strangers in restaurants and confidently start a conversation,
or call long lost friends early in the morning and try to sell them something. On the other hand, a
few people will be irritable (but still energetic) rather than enthusiastic during manic episodes.

In addition to this confidence, the person’s speech usually changes. They usually speak very
quickly, change subject often, and are difficult to interrupt (“Pressured Speech”). They may also
tell a lot of jokes or irrelevant stories. Sometimes their speech becomes theatrical, with dramatic
gestures and bursts of song. They may start using words based on the sound of the words rather
than the meaning of the words. Individuals who are more irritable than enthusiastic during a
manic episode may launch into angry rants or make a lot of hostile comments.

The person may make a lot of demands on people around them. They may have a lot of sexual
ideas or plan romantic conquests.

During a manic episode, the person may be very appealing and charismatic to people who do not
know them. Friends and family, however, will notice the dramatic change from the person’s
normal behavior. After the episode passes, the person may be very embarrassed about their
behavior and its consequences.

Symptoms of the manic phase include:

Elevated mood
Rapid mood shifts (“lability of affect”)
Increased activity
Flight of ideas or racing thoughts
Inflated self-esteem
Decreased need for sleep
Agitation
More talkative than usual or pressure to keep talking
Agitation (difficulty sitting still, pacing, hand wringing)
Poor temper control
Excessively irresponsible behavior



Increased goal-directed activities
Excessive, but impaired, involvement in high risk, pleasurable activities
Delusions
Hallucinations

Some people experience shorter, less intense manic episodes, which last less than a week and do
not completely debilitate them. These are called Hypomanic Episodes, and individuals who
experience them along with major depression are diagnosed with Bipolar II Disorder. However
the symptom list for hypomanic episodes is the same as for manic episodes.

Incidence Statistics for Bipolar Disorder
Bipolar is less common than major depression.
2.3 million adult American experience bipolar disorder each year
Equal number of men and women experience bipolar disorder
Left untreated, a manic episode can last as long as three months
Usually first presents as major depression
Usually has earlier onset than major depression. Bipolar disorder can occur between
childhood and age 50, but the mean age of onset/diagnosis is age 30.
10%-20% of individuals diagnosed with bipolar disorder primarily experience manic
episodes.
On average, the period between manic episodes is 6 to 9 months if untreated. This
interval tends to decrease for a particular person over time.
1/3 of individuals diagnosed with bipolar disorder experience a significant decline in
social skills and experience chronic symptoms.

Common Treatments, Medications, and Side Effects
Treatment of major depression and bipolar disorder is very difficult and usually involves a
variety of approaches. As mentioned above, the exact causes of mood disorders are unknown, so
successful treatment usually involves a combination of medication and psychotherapy. It is also
important to note that employment can often help the treatment and control of mood disorders by
providing some structure and sense of purpose in a person’s life.

Medication
There are many possible medications for depression and bipolar depression, with more appearing
every year. Most of the time individuals with bipolar disorder require a combination of drugs to
address different aspects of their situation. The physician and individual have to use a trial and
error process to find the right combination of drugs and dosages. The process is further
complicated by the fact that most of the drugs take several weeks to several months to reach
effective levels in the person’s body.



In addition, there can be side effects of the drugs that require further drug treatment. Whenever
you begin significantly altering the balance of neurotransmitters and hormones in the body, there
will be an unpredictable cascade of effects on regulatory functions of the body as well. The
physician and individual must pay close attention to possible side effects during the trial and
error process. Uncontrolled side effects can cause permanent damage and lead to secondary
health conditions in some individuals with depression or bipolar depression.

Fortunately, many of the newer drugs have significantly fewer side effects. Unfortunately, this
decrease in side effects is accomplished with a specialization of the effects of the drug, reducing
their general utility. This means that when they work for a person, they work well, but only for a
few people, so the person may have to try many more such drugs to find the right fit. This is part
of the reason drugs for mood disorders are some of the most expensive of all drugs.

Because of these complications, the trial and error process for finding a combination of drugs to
successfully control mood disorders can sometimes take years. It is important that the person is
allowed this time, if possible, and not rushed into a job placement before they feel their mood is
stable and under control. However, financial pressure may not allow that freedom. Even after
stabilization, the person may experience occasionally crisis periods when they and their
physician will need to adjust the medication.

It is not productive to go into great detail here about the different neurotransmitters and the
effects of different drugs related to depression and bipolar depression. The topic is very complex
and the information changes rapidly. It is the job of the physician, not the VR counselor, to stay
current on these topics. However, the VR counselor should know the basic types of drugs that
may be involved. These include:

Antidepressants
• SSRI Antidepressants
• Tricylic Antidepressants
• MAO Inhibitor Antidepressants
Mood Stabilizers
• Lithium
• Some antiseizure medications, including Tegretol and Depakote
• Some antipsychotic medications, including risperidone and quetiapine (Seroquel)
Antipsychotics (if psychosis is part of manic episodes)
Sedatives (if insomnia is an issue)

(see Drugs entry for side effects)



In severe cases of depression that do not respond to medication, the physician may decide to use
Electroconvulsive Therapy (ECT). ECT is essentially a way to trigger an artificial seizure in
the person, since researchers have found that individuals with seizure disorders and depression
often get relief from the depression after a seizure. This is probably due to a massive release of
neurotransmitters into the brain, but no one knows for sure. Physicians deliver ECT in a hospital
setting and in a carefully controlled way. The individual receives a mild anesthesia and muscle
relaxant beforehand so they will experience little pain. The electrodes are carefully positioned to
deliver the electric current in specific parts of the brain. The resulting seizure usually lasts
between 20 and 90 seconds. The individual is usually awake again within 5 or 10 minutes. ECT
treatment usually involves 6 to 10 sessions, with one given every two or three days.

It must be emphasized that ECT is a very controversial treatment. Even through it increased in
popularity in the last few decades, there are still many people who strongly disapprove of it.
Advocates for the therapy say it works very well, providing relief for approximately 70% of
people who receive it (and, remember, it is only used when other treatments have not worked).
They say it has few side effects other than some short-term memory problems. Critics say it does
not work well and it only helps around 30% of the individuals who receive it. They say there are
significant side effects, including major memory problems and permanent brain injury. They also
report that patients getting ECT are generally not told about the risks. The situation is further
complicated by the lack of federal regulation over the administration of ECT.

When ECT works, the person generally has a significant improvement in their mood within two
weeks of the first treatment, but the results also usually fade after a few months. This may be
enough to end the current depressive episode, but the person will need to take medication to
prevent future episodes and may need more ECT treatments if depressive episodes return. As
mentioned above, some individuals find ECT very helpful, with few side effects, while others
find it does not help at all.

In addition to ECT, Psychosurgery/neurosurgery is also sometimes used to treat severe
depression that has resisted all other treatments. See the OCD entry for a description of
psychosurgery treatment.

Possible Functional Issues
Fatigue
Difficulty in making decisions
Difficulty with self care (bathing, dressing, grooming, nutrition)
Difficulty sitting still (psychomotor agitation)
Impaired social skills
Impaired judgment
Difficulty coping with changes
Inconsistent behavior



Difficulty concentrating
Low self esteem, difficulty advocating for themselves
Difficulty sleeping or excessive sleeping (over-sleeping)
Difficulty keeping on schedule

Initial Interview Considerations
Initial Questions
How would they describe their mood? How would they describe the stability of their
mood?
What times of day are best for them, in terms of their mood and energy? What times of
day are worst?
What times of year are best or worst for them? Do they see seasonal cycles?
What types of hobbies or activities do they do when they are feeling good? (gets at skills,
interests)
What sort of side effects, if any, do they experience from their medication?
What sort of things do they do, beside medication, to help control their mood? What
helps them manage their mood?
How do they feel about the medication (if any)? Do they dislike it or have any strong
feelings about it?
How much trouble, if any, do they have remembering to take the medication?
What symptoms do they experience during an episode?
What symptoms do they experience, if any, in between episodes?
How has their mood disorder affected their work? What symptoms have caused the most
trouble at work?
How well do they sleep? How often do they feel sleepy during the day?
How is their stamina? How long can they do something before they feel too tired to
continue?
How do they feel about working in teams or groups? Do they think this would help their
mood? Do they think it would be a challenge for them?

Initial Observations
Do they seem irritable? Some individuals with bipolar disorder may appear irritable
rather than exuberant during their manic phases.
How are their social skills? Some individuals show difficulty with social skills even in
between episodes.



Interview Accommodations (if any)
Confirm, through conversation, that the person understands what has been said and what
their options are. Repeat or rephrase things as often as necessary to help them.
Give them time to make decisions or organize their thoughts. Resist any pressure from
them to make the decisions for them.
Write down, or encourage the person to write down, a summary of what was discussed
and decided, plus what is planned for the future. If the person writes it down, review it
with them to make sure it is complete.

Possible Accommodations and Assistive Technology
Flexible schedule, including options to deal with:
• Sick days on short notice
• Daily rhythms of medication and side effects (when are they at their best
during day)
• Seasonal cycles
Supported employment
Community-based assessment can be very useful for individuals with mood disorders
An office with a sunny window or skylight (sunshine can help lift one’s mood)
Job mentoring by a coworker
Medication reminder devices

Career Planning Issues
If possible, do not try to place them in employment until their moods are stabilized
through treatment. They may not have that flexibility.
If possible, provide plenty of time and opportunities for the person to explore different
employment possibilities. Keep their options open and realize that making firm decisions
may be difficult for them.
With the person’s permission, contact their physician to discuss their mood stability and
their compliance with medication.
Employment can often help the treatment and control of mood disorders by providing
some structure and sense of purpose in their life. On the other hand, attempts to place
them when they are not yet stabilized could lead to failures, making treatment more
difficult.
Periodicity of episodes may be predictable. With some research on medical records, you
should be able to figure out what days of the month or months of the year they have the
most trouble and adjust work schedules accordingly.



Compliance with medication is of paramount importance. Because of possibly significant
side effects, the VR counselor should stay alert to any signs the person is non-compliant
or is self-medicating.
Medical insurance issues to cover expensive medications, including SSA work
incentives, should be addressed.
Assess the need for reliable transportation.
Cognitive skills, problem solving usually not affected (if stabilized)
Dexterity, physical strength not affected
Stamina may be an issue, depending on medications
Support group or job club may be useful

Emerging Issues
New medications and their availability
Acceptance by the community, including employers
The tension between adherence to medication regime and individual choice

Additional Information Resources
National Depressive and Manic-Depressive Association (NDMDA): www.ndmda.org/
National Institute of Mental Health, depression publications:
www.nimh.nih.gov/publicat/depression.cfm
National Mental Health Association (NMHA): www.nmha.org
Focus On Depression, part of MedicineNet.com: www.focusondepression.com
ECT.org (a critical review of electroconvulsive therapy): www.ect.org


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