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Chapter 6 Mood Disorders and Suicide An Overview of Depression and Mania • Mood disorders – Gross deviations in mood – Major depressive episodes – Manic and hypomanic episodes An Overview of Depression and Mania • Types of DSM-IV-TR depressive disorders – Major depressive disorder – Dysthymic disorder – Double depression An Overview of Depression and Mania • Types of DSM-IV-TR bipolar disorders – Bipolar I disorder – Bipolar II disorder – Cyclothymic disorder 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 – Anhedonia – loss of pleasure/interest in usual activities The Structure of Mood Disorders • Mania • Hypomanic episode – Dysphoric manic episode or mixed manic episode The Structure of Mood Disorders • Features of a manic episode – Elevated, expansive mood for at least one week – 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 Major Depression: An Overview • Major depressive disorder – Single episode – highly unusual – Recurrent episodes – more common • From grief to depression – Pathological or impacted grief reaction Dysthymia: An Overview • Overview and defining features – Symptoms are milder than major depression – Persists for at least two years – 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 Double Depression: An Overview • Overview and defining features – Major depressive episodes and dysthymic disorder – Dysthymic disorder often develops first • Facts and statistics – Associated with severe psychopathology – Associated with a problematic future course Bipolar I Disorder: An Overview • Overview and defining features – Alternations between full manic episodes and depressive episodes • Facts and statistics – Average age of onset is 15-18 years – Can begin in childhood – Tends to be chronic – Suicide is a common consequence 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 Cyclothymic Disorder: An Overview • Overview and defining features – Chronic version of bipolar disorder – Manic and major depressive episodes are less severe – Manic or depressive mood states persist for long periods – Must last for at least two years (one year for children and adolescents) Cyclothymic Disorder: An Overview • Facts and statistics – Average age of onset is 12 to 14 years – Most are female – Cyclothymia tends to be chronic and lifelong – One third to one half develop full-blown bipolar Prevalence of Mood Disorders • Worldwide lifetime prevalence – 16% for major depression • 6% have experienced major depression in last year • Sex differences – Females are twice as likely to have major depression – Bipolar disorders equally affect males and females Prevalence of Mood Disorders • Occurs less often in prepubertal children • Rapid rise in adolescents • Adults over 65 have about 50% less than adults • Bipolar same in childhood, adolescence and adults • Prevalence of depression seems to be similar across subcultures Life Span Developmental Influences on Mood Disorders • Three-month-olds can show depression • Children below nine do not show class mania or bipolar symptoms • Mood disorder are often misdiagnosed as ADHD • Children are being diagnosed with bipolar at increasingly high rates Life Span Developmental Influences on Mood Disorders • Depression in elderly between 14% and 42% – Corroccurance with anxiety disorders – Less gender imbalance after 65 years of age • Cultural differences exist – Hopi say they are “Heartbroken” – Native American population have four times the rate as the general population Mood Disorders: Familial and Genetic Influences • Family studies – Rate is high in relatives of probands – Relatives of bipolar probands tend to have unipolar depression Mood Disorders: Familial and Genetic Influences • Twin studies – Concordance rates are high in identical twins • two to three times more likely to present with mood disorders – Severe mood disorders have a strong genetic contribution – Heritability rates are higher for females compared to males, 40% women and 20% men 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 Mood Disorders: Neurobiological Influences • Neurotransmitter systems – Serotonin and its relation to other neurotransmitters – Mood disorders are related to low levels of serotonin – Permissive hypothesis Mood Disorders: Neurobiological Influences • The endocrine system – Elevated cortisol – Hippocampus and neurogenesis • Sleep disturbance – Hallmark of most mood disorders – REM and depression – Relation between depression and sleep 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 of life events and mood – Reciprocal-gene environment model – The relationship between stress and bipolar is also string Mood Disorders: Psychological Dimensions (Learned Helplessness) • The learned helplessness theory of depression – Lack of perceived control over life events Mood Disorders: Psychological Dimensions (Learned Helplessness) • Learned helplessness and a depressive attributional style – Internal attributions • Negative outcomes are one’s own fault – Stable attributions • Believing future negative outcomes will be one’s fault – Global attribution • Believing negative events will disrupt many life activities – All three domains contribute to a sense of hopelessness Mood Disorders: Psychological Dimensions (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 Mood Disorders: Psychological Dimensions (Cognitive Theory) • Cognitive errors and the depressive cognitive triad – Think negatively about oneself – Think negatively about the world – Think negatively about the future • Seligman and Becks theories Mood Disorders: Social and Cultural Dimensions • Marital relations – Marital dissatisfaction is strongly related to depression – This relation is particularly strong in males Mood Disorders: Social and Cultural Dimensions • Mood disorders in women – Females over males – Except bipolar disorders – Gender imbalance likely due to socialization Mood Disorders: Social and Cultural Dimensions • Mood disorders in women – 70% of major depression and dysthymia are women – Perception of uncontrollability – Parenting styles – Stereotypical gender roles – Social networks – Women ruminate more than men Mood Disorders: Social and Cultural Dimensions • Social support – Extent of social support is related to depression – Lack of social support predicts late onset depression – Substantial social support predicts recovery from depression 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 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 are common Treatment of Mood Disorders: Tricyclic Antidepressants • 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 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 Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors • Monoamine oxidase (MAO) – Block monoamine oxidase – This enzyme breaks down serotonin/norepinephrine – Slightly more effective than tricyclics Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors • Must avoid foods containing tyramine – Examples include beer, red wine, cheese – Many patients do not like the dietary restrictions Treatment of Mood Disorders: Lithium • Lithium is a common salt – Primary drug of choice for bipolar disorders – Can be toxic • Side effects may be severe – Dosage must be carefully monitored – Lithium is a mood-stabilizing drug • Why lithium works remains unclear 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 Treatment of Mood Disorders: ECT – Side effects are few and include short-term memory loss – Uncertain why ECT works – Relapse is common • Transcranial Magnetic Stimulation (TMS) – Uses magnets to generate a precise localized electromagnetic pulse Psychosocial Treatments • Cognitive-behavioral therapy – Addresses cognitive errors in thinking – Also includes behavioral components • Interpersonal psychotherapy – Focuses on problematic interpersonal relationships • • • • Prevention Combined treatments for depression Prevention relapse of depression Psychosocial treatments for bipolar Psychosocial Treatments • Outcomes with psychological treatments – Comparable to medications – Research does not suggest advantage for combined treatment 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 • Suicide rates are increasing, particularly in the young 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 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 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 Summary • Suicide is an increasing problem – Not unique to mood disorders • Medications and psychotherapy produce comparable results • High rates of relapse DSM-5 Proposed Changes • http://www.dsm5.org/ProposedRevisions/Pag es/MoodDisorders.aspx