chapter 7 mood disorders and suicide. an overview of depression and mania mood disorders depressive...

Chapter 7

Mood Disorders and Suicide

An Overview of Depression and Mania

Mood Disorders “Depressive disorders” “Affective disorders” “Depressive neuroses” Gross deviations in mood

Depression Mania

An Overview of Depression

Major depressive episode Extreme depression 2 weeks Cognitive symptoms Physical dysfunction Anhedonia Duration - 4 to 9 months, untreated

An Overview of Mania

Manic episode Exaggerated elation, joy, euphoria 1 week, or less Cognitive symptoms Physical dysfunction Duration – 3 to 6 months, untreated

Hypomanic episode

Structure of Mood Disorders

Unipolar disorders Depression or mania alone Typically depression

Bipolar disorders Depression and mania Mixed episodes

Structure of Mood Disorders

Diagnostic considerations Accompanying symptoms

Overlap between disorders Severity Course

Recurrent Alternating Seasonal

Depressive Disorders: An Overview

Major Depressive Disorder No mania/hypomania Single episode

Rare Recurrent

4 episodes (lifetime) Duration – 4 to 5 months

Major Depressive Disorder

Onset Low until early teens Mean age = 30

Dysthymic Disorder Milder symptoms 2+ years Chronic Persistent

Depressive Disorders: An Overview

Onset = early 20’s Early onset = before 21

Greater chronicity Poor prognosis Stronger familial component

Median duration = 5 years Depends on comorbidity

Dysthymic Disorder

Dysthymic Disorder

Double Depression Major depressive episodes and dysthymic

disorder Dysthymia first Severe psychopathology Poor course High recurrence rates

Depressive Disorders: An Overview

Depression frequently follows loss 62% after death

Pathological or Complicated Grief Severity of symptoms Dysfunction Persistence of symptoms

Grief and Depression

Bipolar I Disorder: An Overview

Alternating major depressive and manic episodes

Single manic episode Recurrent

Symptom free for 2 months

Bipolar I Disorder: An Overview

Statistics Onset = age 18

Childhood Chronic Suicide

Bipolar II Disorder

Alternating major depressive and hypomanic episodes

Statistics Onset = age 19 to 22

Childhood Chronic

Cyclothymic Disorder

Alternating manic and depressive episodes Less severe Persists longer

Chronic symptoms Adults = 2+ years children and adolescents= 1+ year

Cyclothymic Disorder

Statistics Onset = age 12 or 14 Chronic Lifelong Female>Male Risks for Bipolar I/II

Symptom Specifiers Atypical Melancholic Chronic Catatonic Psychotic

Mood congruent/ incongruent Postpartum

Additional Defining Criteria

Additional Defining Criteria

Course Specifiers Longitudinal course Rapid cycling pattern Seasonal pattern

Depression vs. mania Melatonin Phototherapy CBT

Additional Defining Criteria

Prevalence of Mood Disorders

Children and Adolescents Similar to adults Symptom presentations Prevalence

Early childhood Adolescence

Misdiagnosis ADHD Conduct disorder

Prevalence of Mood Disorders

Elderly Prevalence may depend on setting Symptom profile Female : Male = 1:1 Diagnostic difficulty Comorbidities

Prevalence of Mood Disorders

Across Cultures Similar prevalence among US subcultures

Exceptions Physical or somatic symptoms Comparability

Prevalence of Mood Disorders

Among the creative Higher prevalence

Melancholia Mania

Gender differences

Prevalence of Mood Disorders

More alike than different Almost all depressed persons are anxious Not all anxious persons are depressed

Negative affect

Core symptoms of depression Anhedonia Slowing Negative cognitions

Overlap of Anxiety and Depression

Familial and Genetic Influences Family Studies Adoption Studies Twin Studies

Bipolar Unipolar

Higher concordance with higher severity Higher heritability for females

Causes of Mood Disorders : Biological

Causes of Mood Disorders : Biological

Shared genetic vulnerability High familial heritability Same genetic factors General predisposition

Except mania?

Depression and Anxiety: The Same Genes?

Neurotransmitter Systems Serotonin - depression The “permissive” hypothesis

Dopamine Norepinephrine

Dopamine - mania

Causes of Mood Disorders : Biological

Endocrine System “Stress hypothesis”

Overactive HPA axis Neurohormones Elevated cortisol Suppressed hippocampal neurogenesis

Dexamethasone suppression test (DST)

Causes of Mood Disorders : Biological

Sleep and Circadian Rhythms REM sleep

Reduced latency Increased intensity

Decreased slow wave sleep

Sleep deprivation effects

Causes of Mood Disorders : Biological

Brain Wave Activity Indicator of vulnerability?

Greater right side anterior activation Less alpha wave activity

Causes of Mood Disorders : Biological

Stressful life events Context Meaning Timing

Effects of stress Poorer treatment response Delayed remission Trigger for episode or relapse

Causes of Mood Disorders : Psychological

Reciprocal-gene environment model Stress triggers depression Depressed individuals create or seek out

stressful situations

Interaction with vulnerability Genetic Psychological

Causes of Mood Disorders : Stress

Learned Helplessness (Seligman) Lack of perceived control

Depressive Attributional Style Internal Stable Global

Also characterizes anxiety

Causes of Mood Disorders : Psychological

Sense of hopelessness Lack of perceived control Will not regain control

Pessimism Before or after?

Causes of Mood Disorders : Psychological

Negative Cognitive Styles Cognitive Theory of Depression (Beck) Cognitive errors in depression

Negative interpretations

Types of Cognitive Errors Arbitrary inference Overgeneralization

Causes of Mood Disorders : Psychological

Beck’s Depressive Cognitive Triad

Causes of Mood Disorders : Psychological

Causes of Mood Disorders : Psychological

Cognitive Theory of Depression (Beck) Negative schemas Automatic thoughts

Treatment implications Correcting the errors

Causes of Mood Disorders : Psychological

Cognitive Vulnerability for Depression Pessimistic explanatory style Negative cognitions Hopelessness attributions

Interactions with: Biological vulnerabilities Stressful life events

Mood Disorders: Social and Cultural Dimensions

Marriage and Interpersonal Relationships

Relationship disruption precedes depression Strongest effects for males

Martial conflict vs. marital support

Gender differences in causal direction

Mood Disorders: Social and Cultural Dimensions

Mood Disorders in Women Prevalence: Females > males True for all mood disorders

Except bipolar

Mood Disorders: Social and Cultural Dimensions

Mood Disorders in Women Gender roles

Perceptions of uncontrollability Socialization

Access to resources

Mood Disorders: Social and Cultural Dimensions

Social Support Related to depression Lack of support

predicts late onset depression Substantial support

predicts recovery for depression (not mania)

Integrative Theory of Mood Disorders

Shared biological vulnerability

Psychological vulnerability

Exposure to Stress

Social and interpersonal relationships

Integrative Theory of Mood Disorders

Treatment of Mood Disorders

Changing the chemistry of the brain Medications ECT Psychological treatment

Treatment : Antidepressant Medications

Tricyclics (Tofranil, Elavil) Frequently used for severe depression Block reuptake/down regulate

Norepinephrine Serotonin

2 to 8 weeks to work Many negative side effects Lethality

Monoamine Oxidase (MAO) Inhibitors Block MAO Higher efficacy Fewer side effects Interactions

Foods Medicines

Selective MAO-Is

Treatment : Antidepressant Medications

Selective Serotonin Reuptake Inhibitors Fluoxetine (Prozac) First treatment choice Block presynaptic reuptake No unique risks

Suicide or violence Many negative side effects

Treatment : Antidepressant Medications

Other medications Venlafaxine

Similar to tricyclics Nefazodone

Similar to SSRIs St. John’s Wort

Questionable efficacy

Treatment : Antidepressant Medications

Other issues Efficacy in special populations

Children Elderly

Preventing relapse Maintaining benefits

Treatment : Antidepressant Medications

Treatment of Mood Disorders: Lithium

Common salt Primary treatment for bipolar disorders Unsure of mechanism of action Narrow therapeutic window

Too little –ineffective Too much – toxic, lethal

Treatment of Mood Disorders: Antimanics

Other antimania drugs Carbamazepine Valproate

Most frequently prescribed High efficacy

Except suicide! Fewer side effects

Electroconvulsive Therapy Brief electrical current Temporary seizures 6 to 10 treatments High efficacy

Severe depression Few side effects Relapse is common

Treatment of Mood Disorders: ECT

Transcranial magnetic stimulation Localized electromagnetic pulse Fewer side effects Efficacy is likely good

More studies needed

Treatment of Mood Disorders: TMS

Psychological Treatment of Mood Disorders

Cognitive Therapy Identify errors in thinking Correct cognitive errors Substitute more adaptive thoughts Correct negative cognitive schemas

Behavioral Activation Increased positive events Exercise

Psychological Treatment of Mood Disorders

Interpersonal Psychotherapy Address interpersonal issues in relationships

Role disputes Loss New relationships Social skill deficits

Psychological Treatment of Mood Disorders

CBT and IPT Outcomes Comparable to medications More effective than:

Placebo Brief psychodynamic treatment

Combined Treatment of Mood Disorders

Possible benefits above individual treatments 48% benefit from meds or CBT 73% benefit from combined

More research is needed

Prevention of Mood Disorders

Universal programs Selected interventions Indicated interventions

Preventing relapse

Psychological Treatment of Bipolar Disorders

Management of interpersonal problems Increase medication compliance Interpersonal and Social Rhythm Therapy Family-focused treatment

Suicide: Statistics

Population specific Caucasians Native Americans

Increasing rates Adolescents Elderly

Gender differences Indices

Attempts Ideations

Suicide: Past Conceptions

Types of suicide (Durkheim) Altruistic Egoistic Anomic Fatalistic

Suicide: Risk Factors

Family history Low serotonin levels Preexisting disorder Alcohol Past suicidal behavior Shameful/humiliating stressor Suicide publicity and media coverage

Suicide: Risk Factors

Suicide: Treatment

Importance of assessment Previous attempts Recent events Ideation Plan Means Access

Suicide: Treatment

No-suicide contract Hospitalization

Complete or partial Problem solving therapy CBT

Future Directions

Interaction between biology and psychology Biological challenge studies Induced depression

Serotonin and pessimism