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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
Depressive Disorders: An Overview
Dysthymic Disorder
Milder symptoms
2+ years
Chronic
Persistent
Dysthymic Disorder
Onset = early 20’s
Early onset = before 21
Greater chronicity
Poor prognosis
Stronger familial component
Median duration = 5 years
Depends on comorbidity
Dysthymic Disorder
Depressive Disorders: An Overview
Double Depression
Major depressive episodes and dysthymic
disorder
Dysthymia first
Severe psychopathology
Poor course
High recurrence rates
Grief and Depression
Depression frequently follows loss
62% after death
Pathological or Complicated Grief
Severity of symptoms
Dysfunction
Persistence of symptoms
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
Additional Defining Criteria
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
Prevalence of Mood Disorders
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
Overlap of Anxiety and Depression
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
Causes of Mood Disorders : Biological
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
Depression and Anxiety: The Same Genes?
Shared genetic vulnerability
High familial heritability
Same genetic factors
General predisposition
Except mania?
Causes of Mood Disorders : Biological
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 : Psychological
Stressful life events
Context
Meaning
Timing
Effects of stress
Poorer treatment response
Delayed remission
Trigger for episode or relapse
Causes of Mood Disorders : Stress
Reciprocal-gene environment model
Stress triggers depression
Depressed individuals create or seek out
stressful situations
Interaction with vulnerability
Genetic
Psychological
Causes of Mood Disorders : Psychological
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
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
Treatment : Antidepressant Medications
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 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
Treatment of Mood Disorders: ECT
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: TMS
Transcranial magnetic stimulation
Localized electromagnetic pulse
Fewer side effects
Efficacy is likely good
More studies needed
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