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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