Mood Disorders and Suicide

SymptomsDiagnosis

Course and OutcomeFrequency

CausesTreatment

Suicide

CHAPTER Five

Major depression is the leading cause of disability worldwide.

Depression accounts for 10% of all disability.

Affect: pattern of observable behaviors Facial expression, pitch of voice, body

movements Mood: a pervasive and sustained emotional

response that can color perception.

OVERVIEW

Mood disorders are defined in terms of episodes- discrete periods of time in which the person’s behavior is dominated by either a depressed or manic mood.

DSM-IV-TR defines 3 mood episodes.1. Major depressive episode

2. Manic episode3. Hypomanic episode

OVERVIEW

The 3 mood episodes form the basis of the 5 mood disorders:

Unipolar disorders – individual experiences only abnormally low moods (major depression, dysthymia).

Bipolar disorders – individual experiences both abnormally low and high moods (Bipolar I, Bipolar II, cyclothymia).

Depression Mania

Overview

Mood Episodes

Mood Episodes

Mood DisordersHypomanic episode - a less extreme

version of a manic episode that is not severe enough to significantly interfere with functioning.

The DSM-IV-TR Mood Disorders1) Major depressive disorder

One or more major depressive episode(s)No history of manic or hypomanic episodesSubtypes

Catatonic FeaturesPsychotic FeaturesMelancholic FeaturesPostpartum OnsetSeasonal Pattern

The DSM-IV-TR Mood Disorders

2) Dysthymic Disorder: Two years or more of consistently depressed mood and other symptoms that are not severe enough to meet criteria for a major depressive episode.

The DSM-IV-TR Mood Disorders3) Bipolar I disorder

Combination of major depressive episodes and manic episodes.

4) Bipolar II disorder Combination of major

depressive episodes & hypomanic episodes.

The DSM-IV-TR Mood Disorders

5) Cyclothymic disorder Two years or more of consistent mood swings between hypomanic highs and dysthymic lows.

Unipolar DisordersAverage age of onset = 32 but impacts

ALL age groups. Length of episodes vary widelyRelapse: a return of active symptomsApproximately ½ patients with MDD

recover in 6 months

COURSE AND OUTCOME

FIGURE 5-1 The Course and Outcome of Major Depression

Bipolar DisordersOnset usually occurs between 18 and 22

years.First onset can be depression or mania.Average duration of a manic episode

runs between 2 and 3 months.Long-term prognosis mixedRapid Cyclers—experiencing at least 4

mood episodes within a 12 month period

COURSE AND OUTCOME

Incidence and Prevalence16% of NSC-R study (n = 9,000)

suffered from depression.Lifetime risk of for bipolar I and II

disorders combined is close to 4%.Ratio of unipolar to bipolar disorders is

at least 5:1.

FREQUENCY

Gender Differences♀ 2-3x more vulnerable to depression

than ♂.♀ are more likely than ♂ to present

for mental health services.More difficult for ♂ to admit to

subjective feelings of distress.Gender differences not typically

observed for bipolar mood disorders.

FREQUENCY

Major losses of important people or rolesseem to play a crucial role in precipitating major depression.

Depression more likely when life events are associated with feelings of humiliation, entrapment and defeat.

Do negative life events cause depression? Or does depression lead to negative events?

Social Factors and Bipolar Disorders

Less attention paid to bipolar disordersWeeks preceding the onset of a manic

episode marked by an increased frequency stressful life events.

Factors different than from depressionSchedule-disrupting eventsGoal attainment

CAUSES

Psychological Factors: Cognitive vulnerabilityAaron Beck – pervasive and persistent negative thoughts central in the onset of depression when activated by a negative event.

Cognitive TriadLearned helplessness—Seligman

CAUSES

Cognitive Distortions

Response Styles and GenderRuminative style (women more likely) Distracting Style (men more likely)

Interpersonal Factors and Social BehaviorsSome depressed people create difficult

circumstances, increase the level of stress. Integration of Cognitive and Interpersonal

FactorsVulnerability to depression influenced by

childhood experiences.

Why do some people become depressed after stressful life events while others do not?

GeneticsTwin Studies

Genes play a more important role in bipolar disorders

Heritability (0–100): bipolar mood disorders have heritability of 80%

PolygenicGenetic Risk and Sensitivity to Stress

Gender, “s” allele of the 5-HTT—NO LONGER CITED AS DEFINITIVE

BIOLOGICAL FACTORS

The Hypothalamic- Pituitary-Adrenal (HPA) Axis is activated in response to stress.

FIGURE 5-5

Brain regions involved in emotions and mood disorders

FIGURE 5-6

NeurotransmittersMore than 100 different

neurotransmitters in the CNS, and each is associated with several types of postsynaptic receptors.

The 3 most likely to play a role in depression are: Serotonin, Norepinephrine, & Dopamine

BIOLOGICAL FACTORS

Cognitive therapyCognitive

restructuringFocuses on helping

patients replace self-defeating thoughts with more rational statements.

Focuses on current relationships, especially familial

Attempts to improve relationships by building communi-cation & problem-solving skills.

TREATMENT: UNIPOLAR DISORDERS

Interpersonal therapy

Unipolar Disorders - Antidepressant MedicationsFour general categories

Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSNRIs), Tricyclics, Monoamine Oxidase Inhibitors (MOA-Is)

Improvement typically four to six weeksCurrent episode often resolved within

12 weeks.Efficacy – only ~ 50%

TREATMENT

SSRI’s Block reuptake of

Serotonin Prozac, Paxil, Zoloft Most frequently used Easier to use Fewer side effects

Sexual dysfunction, weight gain

Less dangerous in event of overdose

Block reuptake of norepinephrine

Imipramine and amitripyline

More side effects:Constipation,

drowsiness, drop in BP, blurred vision

Equal in efficacy as SSRIs

TREATMENT: UNIPOLAR DISORDERS

Tricyclics

SSNRI’s

Effexor, CymbaltaBlock reuptake of

both serotonin and norepinephrine

Long term effects less known

TREATMENT: UNIPOLAR DISORDERS

MAO-I:

Phenelzine (Nardil) Not as effective

tricyclics Side effects:

Consuming foods with tyramine (cheese and chocolate) often increases BP.

Used in treatment of anxiety disorders, particularly agoraphobia and panic.

Electroconvulsive therapy (ECT)

Electromagnetic TreatmentsDeep brain stimulation

Experimental & Alternative Treatments

Lithium

Effective treatment in alleviation of manic symptoms

60% of patients improve

Non-compliance with drug due to side effectsNauseaWeight gainMemory problems

Mood StabilizersDepakot, TegetrolMechanism of how it

works is unknown

TREATMENT: BIPOLAR DISORDERS

Anti Seizure medications

Psychotherapy

Can be effective supplement to biological intervention

Combination of psychotherapy and medication is more beneficial than medication alone.

TREATMENT: BIPOLAR DISORDERS

15 to 20% of all patients with mood disorders will eventually kill themselves.

SUICIDE

SuicideS -- SexA -- AgeD -- Depression

P – Previous Attempt

E – Ethanol AbuseR – Rational ThoughtS – Social SupportO – Organized PlanN – No SpouseS -- Sickness

Classification of SuicideNonsuicidal Self-Injury

Deliberate self-harm without desire for suicide: cutting, burning, scratching the skin

Pain serves as useful purposeTo punish the selfIs a reflection of frustration and

anger.Maladaptive way to regulate

intense, negative emotional states.

SUICIDE

Causes of SuicidePsychological Factors

Psychological pain: social isolation, feelings of being a burden, previous attempts

Biological FactorsReduced levels of serotonin: poor

impulse control; violent and aggressive behaviors

Potential for genetic predispositionSocial Factors

Availability of guns, media

SUICIDE

Treatment of Suicidal PeopleCrisis Centers and Hotlines

Primarily suicide preventionEfficacy for “saving lives” not

demonstratedPeople with most lethal ideations will

not callOffers valuable assistance to people in

distressPsychotherapy

Reduce lethality

SUICIDE

Treatment of Suicidal PeoplePsychotherapy (continued)

Negotiate agreementsProvide supportReplace tunnel vision with a broader

perspectiveMedication

SSRIs in treating depression lowers suicide rates.

SUICIDE