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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
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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
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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
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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