Mood Disorders and Suicide

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Chapter 6

• Mood Disorders and Suicide

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Range of Emotions

• A person with a mood disorder experiences
  emotions that are extreme and, therefore,
  abnormal.

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Types of depressive disorders

• Major depressive disorder
• Dysthymic disorder
• Double depression

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Major Depression An Overview

• Major depressive episode Overview and defining
  features
• Extremely depressed mood lasting at least two
  weeks
• Cognitive symptoms feelings of worthlessness,
  indecisiveness
• Disturbed physical functioning (sleep and eating)
• Anhedonia loss of pleasure/interest in usual
  activities

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Major Depression An Overview

• Major depressive disorder
• Single episode highly unusual
• Recurrent episodes (2 or more major depressive
  episodes separated by at least 2 months of no
  depression) more common
• From grief to depression
• Pathological or impacted grief reaction

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Major Depression An Overview

• Major depressive disorder
• Mean age is 30
• Typical first episode is 4-9 months if untreated

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Dysthymia An Overview

• Overview and defining features
• Symptoms are milder than major depression
• Persists for at least two years in adults, one
  year in children and adolescents
• No more than two months symptom free
• Symptoms can persist unchanged over long periods
  ( 20 years)
• Facts and statistics
• Late onset typically in the early 20s

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Double Depression An Overview

• Overview and defining features
• Major depressive episodes and dysthymic disorder
• Dysthymic disorder often develops first
• Associated with severe psychopathology and
  problematic future course
• High relates of relapse

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Types of bipolar disorders

• Bipolar I disorder
• Bipolar II disorder
• Cyclothymic disorder

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The Structure of Mood Disorders

• Mania
• Hypomanic episode less severe than manic
  episode that lasts at least 4 days

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The Structure of Mood Disorders

• Features of a manic episode
• Elevated, expansive mood for at least one week
• At least 3 of the following
• Inflated self-esteem, decreased need for sleep,
  excessive talkativeness, flight of ideas or sense
  that thoughts are racing, easy distractibility,
  increase in goal-directed activity or psychomotor
  agitation, excessive involvement in pleasurable
  but risky behaviors
• Impairment in normal functioning

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Bipolar I Disorder An Overview

• Overview and defining features
• Alternations between full manic or mixed episodes
  and (but not necessarily) depressive episodes
  and/or hypomania
• Facts and statistics
• Average age of onset is 15-18 years
• Can begin in childhood
• Tends to be chronic and acute
• Suicide is a common consequence as high as 48
  (usually during depressive episodes)

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Bipolar II Disorder An Overview

• Overview and defining features
• Alternations between major depressive and
  hypomanic episodes
• Facts and statistics
• Average age of onset is 19-22 years
• Can begin in childhood
• 10 to 25 of cases progress to full bipolar I
  disorder
• Tends to be chronic

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Cyclothymic Disorder An Overview

• Overview and defining features
• Milder but more chronic version of bipolar
  disorder
• hypomanic and dysthymic episodes that last a long
  time
• Must last for at least two years (one year for
  children and adolescents)

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Cyclothymic Disorder An Overview

• Facts and statistics
• Average age of onset is 12 to 14 years
• 60 are female
• chronic and lifelong
• 1/3 to 1/2 develop bipolar

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Prevalence of Mood Disorders

• Worldwide lifetime prevalence
• 16 for major depression
• Sex differences
• Females are twice as likely to have major
  depression
• Bipolar disorders equally affect males and
  females
• 1 for bipolar disorder

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Prevalence of Mood Disorders

• Occurs less often in prepubertal children
• Rapid rise in adolescence
• Adults over 65 have about 50 less than adults
• Three-month-olds can show depression
• Children below nine do not show classic mania or
  bipolar symptoms
• Mood disorders are often misdiagnosed as ADHD
• Children are being diagnosed with bipolar at
  increasingly high rates

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Life Span Developmental Influences on Mood
Disorders

• Depression in elderly between 14 and 42
• Comorbidity with anxiety disorders
• Less gender imbalance after 65 years of age
• Cultural differences exist
• Hopi Native Americans - Heartbroken
• Native American population - 4 X the rate

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Mood Disorders Familial and Genetic Influences

• Family studies
• Rate is high in first-degree relatives of
  probands (2-3 x greater)
• Relatives of bipolar probands tend to have
  unipolar depression
• Twin studies
• Concordance rates are high in identical twins
  (2-3 x)
• Severe mood disorders have strong genetic
  influence
• Heritability rates are higher for females
  compared to males 40 women and 20 men for
  depression

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Mood Disorders Familial and Genetic Influences

• Twin studies
• Vulnerability for unipolar or bipolar disorder
• Appears to be inherited separately
• Some genetic factors are common for mood and
  anxiety disorders (not mania though)

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Mood Disorders Neurobiological Influences

• Neurotransmitter systems
• Low Serotonin and its relation to other
  neurotransmitters causes mood disorders
• Permissive hypothesis when serotonin is low,
  other neurotransmitters are permitted to become
  dysregulated

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Mood Disorders Neurobiological Influences

• The endocrine system
• Elevated cortisol damages the hippocampus and
  prevents neurogenesis
• Sleep disturbance
• Hallmark of most mood disorders
• REM and depression
• Insomnia and depression linked

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Mood Disorders Psychological Dimensions (Stress)

• Stressful life events
• Stress is strongly related to mood disorders
• Poorer response to treatment
• Longer time before remission
• The relation between context (interpretation) of
  life events and mood
• Reciprocal-gene environment model
• Relationship between stress and bipolar is also
  strong

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Mood Disorders Psychological Dimensions (Learned
Helplessness)

• Learned helplessness (LH)- Lack of perceived
  control over life events
• LH and a depressive attributional style
• Internal attributions
• Negative outcomes are ones own fault
• Stable attributions
• Believing future negative outcomes will be ones
  fault
• Global attribution
• Believing negative events will disrupt many life
  activities

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Mood Disorders Psychological Dimensions
(Becks Cognitive Theory)

• Negative coping styles
• Depressed persons engage in cognitive errors
• Tendency to interpret life events negatively
• Types of cognitive errors
• Arbitrary inference overemphasize the negative
• Overgeneralization negatives apply to all
  situations

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Mood Disorders Psychological Dimensions
(Cognitive Theory)

• Cognitive errors and the depressive cognitive
  triad
• Think negatively about oneself, the world and the
  future
• Negative schema

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Mood Disorders Social and Cultural Dimensions

• Marital relations
• Marital dissatisfaction is strongly related to
  depression especially in males
• Mood disorders in women
• Females over males (7030) except bipolar
  disorders (5050)
• Gender imbalance likely due to socialization
  (perceptions of uncontrollability)
• Social support
• Extent of social support is related to depression
  and predicts recovery from depression

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An Integrative Theory

• Shared biological vulnerability
• Overactive neurobiological response to stress
• Inadequate coping and depressive cognitive style
• Diathesis-stress model
• Biological, psychological and social factors all
  influence the development of mood disorders
• Exposure to stress

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Treatment of Mood Disorders Selective
Serotonergic Reuptake Inhibitors (SSRIs)

• Specifically block reuptake of serotonin
• Fluoxetine (Prozac) is the most popular SSRI
• SSRIs pose some risk of suicide particularly in
  teenagers
• Negative side effects

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Treatment of Mood Disorders Mixed Reuptake
Inhibitors

• Venlafaxine (Effexor)- blocks norepinephrine as
  well as serotonin
• Nefazodone (Serzone) improves sleep efficiency
• Both have fewer side effects than SSRIs

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Treatment of Mood Disorders Monoamine Oxidase
(MAO) Inhibitors

• Monoamine oxidase (MAO)
• Block monoamine oxidase enzyme that breaks down
  serotonin and norepinephrine
• Slightly more effective than tricyclics
• Must avoid foods containing tyramine
• Examples include beer, red wine, cheese
• Many patients do not like the dietary
  restrictions

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Treatment of Mood Disorders Tricyclic
Antidepressants

• Used to be widely used (e.g., Tofranil, Elavil)
• Block reuptake
• Norepinephrine and other neurotransmitters
• Therapeutic effects
• Can take two to eight weeks
• Negative side effects are common
• May be lethal in excessive doses so not good for
  suicidal tendencies

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Treatment of Mood Disorders Lithium

• Lithium carbonate is a common salt
• Primary drug of choice for bipolar disorders (50
  reduction in symptoms)
• Can be toxic
• Side effects may be severe
• Dosage must be carefully monitored
• Lithium is a mood-stabilizing drug
• Why lithium works remains unclear

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Treatment of Mood Disorders Electroconvulsive
Therapy (ECT)

• ECT is effective for cases of severe depression
• The nature of ECT
• Involves applying brief electrical current to the
  brain
• Results in temporary seizures
• Usually six to 10 outpatient treatments are
  required
• Side effects are few and include short-term
  memory loss
• Uncertain why ECT works
• Relapse is common (60)

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Psychosocial Treatments

• Cognitive-behavioral therapy
• Addresses cognitive errors in thinking
• Also includes behavioral components
• Interpersonal psychotherapy
• Identifies stressors and focuses on problematic
  interpersonal relationships
• Prevention
• Combined treatments for depression more effective
  (73 versus 48)
• Prevention relapse of depression
• Psychosocial treatments for bipolar

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The Nature of Suicide Facts and Statistics

• 11th leading cause of death in the United States-
  maybe two to three times higher
• Overwhelmingly a white and Native American
  phenomenon
• China and suicide rates (more females)
• Suicidal ideation - thinking seriously about
  suicide
• Suicidal plan formulation of a specific method
• Suicidal attempt person survives

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The Nature of Suicide Facts and Statistics

• Gender differences
• Males are more successful at committing suicide
  than females
• Females attempt suicide more often than males

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The Nature of Suicide Risk Factors

• Risk factors
• Suicide in the family
• Low serotonin levels
• Preexisting psychological disorder
• Alcohol use and abuse
• Stressful life event
• Past suicidal behavior
• Suicide contagion
• Treatment

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Summary of Mood Disorders

• All mood disorders share
• Gross deviations in mood
• Common biological and psychological vulnerability
• Occur in children, adults, and the elderly
• Onset, maintenance, and treatment are affected by
• Stress
• Social support

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Summary

• Suicide is an increasing problem
• Not unique to mood disorders
• Medications and psychotherapy produce comparable
  results
• High rates of relapse

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DSM-5 Proposed Changes

• http//www.dsm5.org/ProposedRevisions/Pages/MoodDi
  sorders.aspx