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CHAPTER 6
MOOD DISORDERS AND SUICIDE
CHAPTER OVERVIEW
This chapter outlines the characteristic features of mood disorders (major depressive
disorder, persistent depressive disorder, double depression, bipolar I disorder, bipolar II disorder,
and cyclothymia). Specifically, the epidemiology, etiology, and treatment of these conditions are
described. Symptom feature modifiers, or those additional factors that have implications for
predicting course or response to treatment, are also covered. This chapter is also devoted to the
phenomenon of suicide, including prevention of and intervention for suicidal ideation and intent.
Various clinical examples are presented throughout the chapter. Extensive discussion of the
changes in mood disorders seen in the DSM-5 revision is included, along with implications for
how those changes will impact our understanding of these disorders.
LEARNING OBJECTIVES
1.
2.
3.
4.
5.
6.
7.
Differentiate a depressive episode from a manic and hypomanic episode.
Describe the clinical symptoms of major depressive disorder, persistent depressive
disorder, and bipolar disorder.
Differentiate major depressive disorder from persistent depressive disorder and
distinguish bipolar disorder from cyclothymic disorder.
Describe the differences in prevalence of mood disorders across the life span.
Describe the biological, psychological, and sociocultural contributions to the
development of unipolar and bipolar mood disorders.
Describe medical and psychological treatments that have been successful in
treating mood disorders.
Describe the relationship between suicide and mood disorders, including known
risk factors and approaches to suicide prevention and treatment.
CHAPTER OUTLINE
UNDERSTANDING AND DEFINING MOOD DISORDERS
An Overview of Depression and Mania
The Structure of Mood Disorders
Depressive Disorders
Other Depressive Disorders
Bipolar Disorders
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PREVALENCE OF MOOD DISORDERS
Prevalence in Children, Adolescents, and Older Adults
Life Span Developmental Influences on Mood Disorders
Across Cultures
CAUSES OF MOOD DISORDERS
Biological Dimensions
Psychological Dimensions
Social and Cultural Dimensions
An Integrative Theory
TREATMENT OF MOOD DISORDERS
Medications
Electroconvulsive Therapy and Transcranial Magnetic Stimulation
Psychological Treatments for Depression
Combined Treatments for Depression
Preventing Relapse of Depression
Psychological Treatments for Bipolar Disorder
SUICIDE
Statistics
Causes
Risk Factors
Is Suicide Contagious?
Treatment
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DETAILED OUTLINE
Understanding and Defining Mood Disorders
What is the difference between a depressive episode and a manic or hypomanic episode?
 Mood disorders are among the most common psychological disorders, and the risk of
developing them is increasing worldwide, particularly in younger people.
 Two fundamental experiences can contribute either singly or in combination to all specific
mood disorders: a major depressive episode and a manic episode. A less severe episode of
mania that does not cause impairment in social or occupational functioning is known as a
hypomanic episode. An episode of mania coupled with anxiety or depression is known as a
mixed episode or mixed state.
 DISCUSSION POINT:
Many people with bipolar disorder demonstrate poor insight during manic episodes. How
might the experience of a manic episode be reinforcing, and what are the implications for
treatment?
 An individual who suffers from episodes of depression only is said to have a unipolar
disorder. An individual who alternates between periods of depression and mania has a bipolar
disorder.
 DISCUSSION POINT:
Why might bipolar disorder confer a higher risk for suicide than major depression does?
What are the clinical symptoms of major depressive disorder, persistent depressive disorder, and
bipolar disorder?
 Major depressive disorder may be a single episode or recurrent, but it is always time-limited.
In another form of depression, persistent depressive disorder, the symptoms are often
somewhat milder but remain relatively unchanged over long periods. In some cases, fewer
symptoms are observed than in a major depressive episode, but they persist for at least two
years (dysthymia); in other cases, a major depressive episode will last at least two years
(chronic major depressive episode). In cases of double depression, a form of persistent
depressive disorder, an individual experiences both major depressive episodes and
dysthymia.
 Approximately 7% of bereaved individuals may experience a pathological, complicated grief
reaction in which the normal grief response develops into a full-blown mood disorder.
 The key identifying feature of bipolar disorders is an alternation of manic episodes and major
depressive episodes. Cyclothymic disorder is a milder but more chronic version of bipolar
disorder.
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 Patterns of additional features that sometimes accompany mood disorders, called specifiers,
may predict the course or patient response to treatment, as does the temporal patterning or
course of mood disorders. One pattern, seasonal affective disorder, most often occurs in
winter.
 DISCUSSION POINT:
What are some of the possible explanations for postpartum onset of depression, in both
mothers and fathers?
 Premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder have
both been added to DSM-5. PMDD is marked by severe and sometimes incapacitating moodrelated symptoms that precipitate a woman’s menstrual period. Disruptive mood
dysregulation disorder is marked by frequent temper outbursts that involve extreme verbal
and/or physical acts of aggression, an absence of indications of manic episodes that would
indicate a bipolar-related illness, and presence of symptoms prior to the age of 6 years.
Prevalence of Mood Disorders
How does the prevalence of mood disorders vary across a life span?
 Though serious when they do occur, mood disorders are less common in prepubertal
children, but rise dramatically in adolescence. They are also seen equally in younger boys
and girls, but are seen far more in females than in males during adolescence. Among those
over the age of 65, estimates suggest that half or more suffer from symptoms of depression.
 Bipolar disorder is seen in about 1% of children, adolescents, and adults.
 The experience of mood disorders across cultures varies, and it can be difficult to make
comparisons, especially, for example, when we attempt to compare subjective feelings of
depression.
Causes of Mood Disorders
What biological, psychological, and sociocultural factors contribute to the development of mood
disorders?
 The causes of mood disorders lie in a complex interaction of biological, psychological, and
social factors. From a biological perspective, researchers are particularly interested in the
stress hypothesis and the role of neurohormones. Psychological theories of depression focus
on learned helplessness and the depressive cognitive schemas, as well as interpersonal
disruptions.
Treatment of Mood Disorders
What medical and psychological treatments have been successful in treating mood disorders?
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 A variety of treatments, both biological and psychological, have proved effective for mood
disorders, at least in the short term. For those individuals who do not respond to
antidepressant drugs or psychosocial treatments, a more dramatic physical treatment,
electroconvulsive therapy, is sometimes used. Transcranial magnetic stimulation, a less
invasive form of biomedical treatment than ECT, has shown some recent promise, but ECT
remains more effective for severe or treatment-resistant psychotic depression. Two
psychosocial treatments—cognitive therapy and interpersonal therapy—seem effective in
treating depressive disorders.
 DISCUSSION POINT:
Have students talk about their perceptions of ECT and where those perceptions originated.
Encourage them to discuss how the actual practice of ECT may be similar to, and different
from, their preconceived notions.
 Relapse and recurrence of mood disorders are common in the long term, and treatment
efforts must focus on maintenance treatment, that is, on preventing relapse or recurrence.
Suicide
What is the relationship between suicide and mood disorders?
 Suicide is often associated with mood disorders but can occur in their absence or in the
presence of other disorders. It is the 11th leading cause of death among all people in the
United States, but among adolescents, it is the 3rd leading cause of death. Experts suggest that
the actual rate of suicide may be drastically under-reported, leading to a concern that it is in
fact a much bigger problem than has been realized.
 In understanding suicidal behavior, three indices are important: suicidal ideation (serious
thoughts about committing suicide), suicidal plans (a detailed method for killing oneself),
and suicidal attempts (that are not successful). Important, too, in learning about risk factors
for suicides is the psychological autopsy, in which the psychological profile of an individual
who has committed suicide is reconstructed and examined for clues.
KEY TERMS
mood disorders, 202
major depressive episode, 202
mania, 203
hypomanic episode, 203
mixed features, 204
major depressive disorder, 204
recurrent, 204
persistent depressive disorder (dysthymia),
204
double depression, 205
integrated grief, 206
complicated grief, 206
premenstrual dysphoric disorder, 208
disruptive mood dysregulation disorder, 208
bipolar II disorder, 210
bipolar I disorder, 210
cyclothymic disorder, 211
neurohormones, 218
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learned helplessness theory of depression,
221
depressive cognitive triad, 222
mood-stabilizing drugs, 230
electroconvulsive therapy (ECT), 230
cognitive therapy, 231
interpersonal psychotherapy (IPT), 232
maintenance treatment, 233
suicidal ideation, 237
suicidal plans, 237
suicidal attempts, 237
psychological autopsy, 238
IDEAS FOR INSTRUCTION
1.
Activity: Suicide Questionnaire. Give students HANDOUT 6.1 to enable them to test
their knowledge about suicide. After they have completed the handout, discuss the correct
answers with them and address concerns voiced by class members. Correct answers:
a. (F) Although there may be some people who talk about suicide but never follow
through, those who talk about suicide are at high risk for suicide. Many who
successfully kill themselves have made earlier threats to do so.
b. (F) Many people are suicidal for a short period of time; some who make it
through a suicidal crisis recover completely.
c. (F) Many people offer clues they are considering suicide before they attempt to
kill themselves. About 80% of suicide attempts are preceded by a warning of
some kind.
d. (F) Talking about suicide can be helpful in prevention and does not trigger the act.
In fact, you may show the person that you are not frightened and are willing to
talk about it with them.
e. (T) A depressed person who gives away valued possessions may be preparing for
suicide.
f. (F) A sudden recovery from depression is a clue the person is considering suicide
and has attained peace of mind as a consequence of their plan.
2.
Activity: Suicide Prevention. You may want to give your students HANDOUT 6.2 on
suicide prevention. Discuss students’ reactions to the suggestions and add any
recommendations that class members may have regarding helping someone who is
suicidal. You may also use the discussion as an opportunity to talk about assisted suicide.
3.
Activity: Screening for Disorders in Primary Care. Break students into groups and
have them imagine that they are in charge of implementing a screening program to detect
mood disorders and suicidality among patients in the clinic. Stress that, because of
demands on physicians’ time, they must limit their screening questionnaire to five items.
Discuss how they selected the items they chose, as well as the difficulty of detecting
serious mood symptoms in the general population.
4.
Video Activity: Abnormal Psychology, Inside/Out, Vol. 1. After reviewing the nature
of depressive disorders, present the video segment depicting Barbara, but do not let on
about her diagnosis. Ask students to see if they can arrive at a diagnosis for Barbara. The
correct answer is unipolar depression, without psychosis.
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5.
Mood Disorders and the DSM-5. Develop a lecture on the changes in the DSM-5 and
how they affected mood disorders. The changes have had a profound effect on how we
diagnose and understand mood disorders. Use
http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
6.
Invite a guest speaker who is a psychologist or psychiatrist specializing in treatment of
mood disorders. Have the students develop questions during the class period before the
guest lecturer is scheduled.
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HANDOUT 6.1
WHAT DO YOU KNOW ABOUT SUICIDE?
Respond to each of the following questions by answering true or false:
1.
_____
People who talk about suicide rarely follow through and actually attempt or
commit suicide.
2.
_____
People who are suicidal will remain suicidal their entire lives.
3.
_____
Almost all suicides take place with little or no warning.
4.
_____
Talking about suicide often precipitates a desire to follow through and do it.
5.
_____
Giving away valued possessions is a clue that a person may be considering
suicide.
6.
_____
Someone who is recovering from severe depression and suddenly develops a
positive outlook on life rarely commits suicide.
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HANDOUT 6.2
SUICIDE PREVENTION
Although there is no one best way to approach a situation where suicide may be a
possibility, the guidelines that follow may be helpful:
1.
Treat the person as a normal human being.
2.
Don’t consider the person too vulnerable or fragile to talk about the possibility of suicide.
Raise the subject yourself by asking the person directly. For example, “It sounds like you
are feeling depressed. Have you been thinking about harming or hurting yourself or
committing suicide?”
3.
Show the person you care about them even if you don’t know them very well.
4.
Help the person talk about and clarify the problem. Those who are depressed may have
difficulty pinpointing the problem and may feel frustrated and confused.
5.
Listen carefully. People who are considering suicide are in mental and/or physical pain,
although you may not be able to guess the type of pain or the source of the problem. Be
there to help the person talk about the issue. You don’t need to fix the problem.
6.
Suicide is often viewed as the final solution to an overwhelming problem. The person who
is depressed may have difficulty sorting out alternative solutions to the problem(s) he/she
faces.
7.
Encourage the person to seek professional assistance. Crisis hotlines are available in many
communities. If an immediate danger of suicide exists, do not leave the person alone. If
the crisis seems to be improved for the moment, be sure you have a plan of action
regarding professional help before leaving the person. Have the person promise to call you
before doing any harm to him/herself. Offer to accompany him/her to see a mental health
professional.
8.
If a friend refuses help, you may need to contact someone close to him/her such as a
family member to share your concerns.
9.
Maintain contact with your friend.
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HANDOUT 6.3
THE MOOD DISORDER QUESTIONNAIRE
Items in this questionnaire are intended as a screening instrument. Please answer each
question as best you can by circling either yes or no:
1. Has there ever been a period of time when you were not your usual self and
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Yes
No
...you felt so good or so hyper that other people thought you were not your
normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or
arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble
concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you
telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have
thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?
2. If you checked YES to more than one of the above, have several of these ever happened during
the same period of time?
Yes No
3. How much of a problem did any of these cause you, such as being unable to work; having
family, money or legal troubles; or getting into arguments or fights? Please select one response
only.
No Problem
Minor Problem
Moderate Problem
Serious Problem
Source Information. This screening tool was developed by the National Depressive and
Manic-Depressive Association and is available at http://www.dbsalliance.org/pdfs/MDQ.pdf s
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SUPPLEMENTARY READING MATERIAL
Barnett, P. A., & Gotlib, I. H. (1988). Psychosocial functioning and depression:
Distinguishing among antecedents, concomitants, and consequences. Psychological
Bulletin, 104, 97–126.
Beck, A. T. (1987). Cognitive therapy of depression. New York: Guilford.
Beck, J. S., & Beck, A. T. (2011). Cognitive behavior therapy: basics and beyond (2nd
ed.). New York: Guilford Press.
Bernard, M. E., & DiGuiseppe, R. (Eds.) (1989). Inside rational-emotive therapy. New
York: Academic Press.
Burns, D. D. (1989). The feeling good handbook. New York: Plume.
Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and
therapy of depression. Philadelphia: Wiley.
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA:
Houghton Mifflin Company. Chapter 5, Major Depressive Disorder. Chapter 6, Bipolar
Disorder.
Copeland, M. E. (1994). Living without depression and manic depression: A workbook
for maintaining mood stability. New York: New Harbinger.
Coyne, J. C., & Gotlib, I. H. (1983). The role of cognition in depression: A critical
appraisal. Psychological Bulletin, 94, 472–505.
Dobson, K. S . (1989). A meta-analysis of the efficacy of cognitive therapy for
depression. Journal of Consulting and Clinical Psychology, 57, 414–419.
Faedda, G., Tondo, L., & Ross, J. (1993). Seasonal mood disorders: Patterns of seasonal
recurrence in mania and depression. Archives of General Psychiatry, 50, 17-23.
Fremouw, W. J., Perczel, W. J., & Ellis, T. E. (1990). Suicide risk: Assessment and
response guidelines. New York: Pergamon.
Goodwin, F. K., & Jamison, K. R. (2007). Manic-depressive illness: bipolar disorders and
recurrent depression (2nd ed.). New York, N.Y.: Oxford University Press.
Gotlib, I. H. (1987). Treatment of depression: An interpersonal systems approach. New
York: Pergamon.
Kolata, G. (1986). Manic-depression: Is it inherited? Science, 232, 575–576.
101
Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices
and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 4 Mood Disorders.
Styron, W. (1990). Darkness visible: A memoir of madness. New York: Vintage.
Thayer, R. E. (1996). The origin of everyday moods. New York: Oxford University.
Wender, P. H. et al. (1984). Psychiatric disorders in the biological and adoptive families
of adopted individuals with affective disorders. Archives of General Psychiatry, 43, 923–
929.
Young, J. E., & Klosko, J. S. (1993). Reinventing your life: How to break free of negative
life patterns. New York: Dutton.
SUGGESTED VIDEOS
Abnormal Psychology, Inside/Out. (available through your Cengage Learning
representative). This volume presents an interview with a patient named Barbara, who is
experiencing a major depressive episode. Barbara notes that she was depressed most of her life,
beginning in high school when she had a headache that lasted for one and a half years. She
describes her current dissatisfaction with her appearance, sleep disturbances, overeating while
depressed, and problems with social withdrawal. Barbara was diagnosed with unipolar
depression, without psychosis. (11 min)
The second segment presents the case of Mary, who was diagnosed with bipolar
depression with psychotic symptoms. During the first interview, Mary is experiencing a
depressive episode, whereas during the second interview, she is in the midst of a manic episode.
(15 min)
A segment on this DVD provides an overview of the characteristics of MDD, including
an interview with a female client who describes her experience when she is in the midst of a
major depressive episode. The female client also talks about her decision to commit suicide. A
related segment, titled “Feeling Bad,” covers the feelings that accompany major depression,
whereas the segment “Feeling Better After Treatment,” presents an interview with a female
client who describes the stigma she experiences with MDD, how her life improved with
treatment, and the importance of asking for help. (7 min)
Antidepressant agents. (Insight Media). This video examines the causes and
manifestations of depression. It considers neurotransmitters and receptors in the brain; presents
theories related to how medication provides relief from depression; and examines the three
categories of antidepressant agents—tricyclic agents, selective serotonin reuptake inhibitors, and
monoamine oxidase inhibitors. (23 min)
Breaking the dark horse: A family copes with manic depression. (Fanlight Productions).
The video presents a story of a woman with manic depression and how it affects her family and
friends. (32 min)
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CBT for depressed adolescents. (Insight Media). This three-part video presents cognitivebehavioral intervention for adolescents with depression. It reviews the theoretical basis for
cognitive-behavioral treatment (CBT) and then provides illustrative vignettes. Finally, it
discusses potential difficulties encountered when using CBT with adolescents and their families.
(130 min)
The choice of a lifetime. (Fanlight Productions). This disturbing, but ultimately inspiring,
film is told from the point of view of six people, ages 21 to 73, who stepped back from the brink
of suicide. In candid interviews, they examine the circumstances that led to their despair, the
forces that stopped them, and the methods of healing they discovered, including therapy, support
groups, spirituality, and artistic expression. (53 min)
Demonstration of the cognitive therapy of depression. (Insight Media). Aaron Beck, one
of the major proponents of cognitive theory and developer of the Beck Depression Inventory,
demonstrates his method of cognitive therapy for depression in this interview with a depressed
and suicidal woman. The tape illustrates how to conceptualize a patient in a cognitive
framework. (40 min)
The depressed child. (Insight Media). Seven percent of children and 27 percent of
adolescents meet the criteria for major depressive disorder. If left undiagnosed, depression can
have negative long-term effects or lead to suicide. This video examines the problem of youth
depression and discusses such treatment options as counseling and antidepressant medications.
(25 min)
Depression and manic depression. (Insight Media). Explaining that many cases of clinical
depression remain untreated due to issues of stigma and fear, this video explores the relationship
between untreated depression and suicide, using as examples the depressions of such well-known
public figures as Mike Wallace and Kay Redfield Jamison. (28 min)
Four lives: A portrait of manic-depression. (Insight Media). This video explores the
psychological effects of bipolar affective disorder by examining four patients. Psychiatrists
discuss the history and treatment of each patient, describing the rapid mood swings from
depression to mania and considering common manifestations of these moods. The program also
examines the uses of ECT, lithium treatment, and psychotherapy. (60 min)
Girl, interrupted. This film, set in the 1960s, illustrates a compelling true story of a
woman who attempted suicide and subsequently self-committed to a mental institution. The
range of psychopathology of the characters, including the depiction of treatment and life in a
mental institution during the 1960s, is outstanding. This film nicely illustrates depression,
suicide, but may be useful for personality disorders, schizophrenia, and ethical and legal issues
as well.
The hospital. George C. Scott depicts a suicidal physician.
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It’s a wonderful life. This film presents Jimmy Stewart as a down-on-his-luck family man
who responds to the stress of life in Bedford Falls by attempting suicide.
Life upside down. French film about an ordinary young man who becomes increasingly
detached from the world. He is eventually hospitalized and treated, but without much success.
The mosquito coast. Harrison Ford plays an eccentric American inventor who flees the
U.S. for Central America because of his paranoia. His behavior throughout the film is bipolar
and certainly manic.
Ordinary people. This film deals with depression, suicide, and family pathology and
presents a sympathetic portrayal of a young man who probably meets DSM-5 criteria for both
PTSD and depression. Also addresses the issue of completed and attempted suicide, as well as
ongoing suicidal ideation.
Psychopharmacology for the 21st century: Antidepressants. (Insight Media). In this
program, Joel Holiner provides an in-depth overview of antidepressants, reviewing their
efficacies, dosages, and side effects. He discusses uses of tricyclics, heterocyclics, lithium, and
MAOIs for treating depression, anxiety, social phobia, bulimia, and OCD. He also presents
recommendations for antidepressant use during pregnancy and highlights the advantages of the
newest SSRIs, including Luvox and Celexa, the latest SS -Norepinephrine reuptake inhibitor. (30
min)
Silver linings playbook. In this film, a man with bipolar disorder, upon his release from a
psychiatric hospital, moves back home determined to get his life back on track and win back his
ex-wife. This film offers a good portrayal of the interpersonal turbulence that can accompany
mood disorders.
Treatment strategies for the management of chronic depression. (Insight Media). An
estimated 5% of depression victims suffer from lifelong, chronic depression. This program
explores how outcomes may be complicated by comorbid psychiatric and medical conditions as
well as chronic stressors. It discusses the diagnosis of chronic depression and presents
management strategies and challenges for the clinician. (90 min)
ONLINE RESOURCES
Bipolar I Disorder
http://www.mentalhealth.com/home/dx/bipolar.html
Internet Mental Health provides this informative webpage; information on other disorders
is provided as well.
Cyclothymia
http://www.mentalhealth.com/home/dx/cyclothymic.html
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Internet Mental Health provides this informative webpage; information on other disorders
is provided as well.
Depression and Bipolar Support Alliance
http://www.dbsalliance.org/
Provides a number of links and resources related to mood disorders.
Depression Central
http://www.psycom.net/depression.central.html
Dr. Ivan’s Depression Central offers links to several sites on mood disorders, including
sites for books, videos, research, diagnosis, and treatment.
Persistent Depressive Disorder (Dysthymia)
http://www.mentalhealth.com/home/dx/dysthymic.html
Internet Mental Health provides this informative webpage; information on other disorders
is provided as well.
Psychology Information Online
http://www.psychologyinfo.com/depression/index.html
A useful resource to information about the nature of mood disorders, including links to other
related sites.
Genetics and Depressive Disorders
http://www.psycom.net/depression.central.genetics.html
Depression Central is an extremely thorough clearinghouse for information on all mood
disorders.
Major Depressive Disorder
http://www.mentalhealth.com/home/dx/majordepressive.html
Internet Mental Health provides this informative webpage; information on other disorders
is provided as well.
Medline Plus – Premenstrual Dysphoric Disorder
http://www.nlm.nih.gov/medlineplus/ency/article/007193.htm
Information from the National Institutes of Health about causes, symptoms, and treatment
of PMDD.
The American Association of Suicidology
http://www.suicidology.org
Website of AAS which provides a wealth of information about suicide research and
prevention.
The American Foundation for Suicide Prevention
http://www.afsp.org/
Website of AFSP, an organization dedicated to understanding and preventing suicide
through research, education, and advocacy.
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WARNING SIGNS
OF DEPRESSION
The following signs and symptoms are considered indicators of depression if
they persist for a period of more than two weeks:
 Feeling sad or empty most of the day, nearly every day
 Reduced interest and pleasure in activities
 Significant unintentional weight loss or gain or a change in appetite
 Over or under sleeping
 Feeling worthless, hopeless, and/or inappropriately guilty
 Recurrent thoughts of death or suicide
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WARNING SIGNS
OF CHILDHOOD DEPRESSION
The following signs and symptoms are considered indicators of depression if
they persist for a period of more than two weeks:
 Persistent sadness and hopelessness
 Withdrawal from friends and activities once enjoyed
 Increased irritability or agitation
 Missed school or poor school performance
 Changes in eating and sleeping habits
 Indecision, lack of concentration, or forgetfulness
 Poor self-esteem or guilt
 Frequent physical complaints, such as headaches and stomachaches
 Lack of enthusiasm, low energy, or lack of motivation
 Drug and/or alcohol abuse
 Recurring thoughts of death or suicide
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WARNING SIGNS
OF BIPOLAR DISORDER
Increased energy
 Decreased sleep, little fatigue
 An increase in activities
 Restlessness
Speech disruptions
 Rapid, pressured speech
 Incoherent speech, clang associations
Impaired judgment
 Lack of insight
 Inappropriate humor and behaviors
 Impulsive behaviors
 Financial extravagance
 Grandiose thinking
Increased or decreased sexuality
Changes in thought patterns
 Distractibility
 Creative thinking
 Flight of ideas
 Disorientation
 Disjointed thinking
 Racing thoughts
Changes in mood
 Irritability
 Excitability
 Hostility
 Feelings of exhilaration
Changes in perceptions
 Inflated self-esteem
 Hallucinations
 Paranoia
 Increased religious activities
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WARNING SIGNS
OF MANIA AND HYPOMANIA
 Insomnia or difficulty sleeping
 Writing pressure
 Others seem slow
 Irritability or surges of energy
 Making lots of plans
 Flight of ideas
 Pressured speech
 Poor judgment and/or inappropriate behavior
 Increased alcohol consumption
 Spending too much money
 Very productive
 Taking too many responsibilities
 Feeling superior
 Increased creativity
 Dangerous driving
 Unnecessary phone calls
 More sensitive than usual
 Increased appetite and sexual activity
 Noises louder than usual
 Doing several things at once
 Inability to concentrate
 Friends notice behavior change
 Difficulty staying still
 Sociable and thrill seeking
 Anxious and wound-up
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WARNING SIGNS
FOR SUICIDE (GENERAL)
 Verbal suicide threats or statements
 Previous suicide attempt
 Risk-taking behavior, reckless behavior
 Final arrangements: giving away prized possessions, making peace, tying up
loose ends
 Neglect of academic work and/or personal appearance
 Separation from loved ones or significant others
 Themes in writing or art about death, depression, or suicide
 Talk of wanting to die
 Chronic depression; prolonged grief after a loss
 Unusual purchases: gun, rope, medications; gathering of pills or poisons
 Unusual sadness, discouragement, and loneliness
 Unexpected happiness (sudden happiness following prolonged depression)
 Physical complaints, hyperactivity, substance abuse, aggressiveness
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