Chapter 6

Mood Disorders and Suicide

Range of Emotions

• A person with a mood disorder experiences emotions that are extreme and, therefore, abnormal.

Types of depressive disorders

– Major depressive disorder– Dysthymic disorder– Double depression

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

(sleep and eating)– Anhedonia – loss of

pleasure/interest in usual activities

Major Depression: An Overview

• Major depressive disorder– Single episode – highly unusual – Recurrent episodes (2 or more

major depressive episodes separated by at least 2 months of no depression) – more common

• From grief to depression– Pathological or impacted grief

reaction

Major Depression: An Overview

• Major depressive disorderMean age is 30Typical first episode is 4-9 months if untreated

Dysthymia: An Overview

• Overview and defining features– Symptoms are milder than major depression– Persists for at least two years in adults, one year in

children and adolescents– 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– Associated with severe psychopathology and

problematic future course– High relates of relapse

Types of bipolar disorders

– Bipolar I disorder– Bipolar II disorder– Cyclothymic disorder

The Structure of Mood Disorders

• Mania• Hypomanic episode – less severe than manic

episode that lasts at least 4 days

The Structure of Mood Disorders

• Features of a manic episode– Elevated, expansive mood for at least one week

• At least 3 of the following:– 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

Bipolar I Disorder: An Overview

• Overview and defining features– Alternations between full manic or mixed

episodes and (but not necessarily) depressive episodes and/or hypomania

• Facts and statistics– Average age of onset is 15-18 years– Can begin in childhood– Tends to be chronic and acute– Suicide is a common consequence – as high as

48% (usually during depressive episodes)

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– Milder but more chronic version of bipolar disorder– hypomanic and dysthymic episodes that last a long

time– 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– 60% are female– chronic and lifelong– 1/3 to 1/2 develop bipolar

Prevalence of Mood Disorders

• Worldwide lifetime prevalence– 16% for major depression

• Sex differences– Females are twice as likely to have major depression– Bipolar disorders equally affect males and females– 1% for bipolar disorder

Prevalence of Mood Disorders

• Occurs less often in prepubertal children• Rapid rise in adolescence• Adults over 65 have about 50% less than adults• Three-month-olds can show depression• Children below nine do not show classic mania or

bipolar symptoms • Mood disorders 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%– Comorbidity with anxiety disorders– Less gender imbalance after 65 years of age

• Cultural differences exist– Hopi Native Americans - “Heartbroken”– Native American population - 4 X the rate

Mood Disorders: Familial and Genetic Influences

• Family studies – Rate is high in first-degree relatives of probands (2-3 x

greater)– Relatives of bipolar probands tend to have unipolar

depression

• Twin studies– Concordance rates are high in identical twins (2-3 x)– Severe mood disorders have strong genetic influence – Heritability rates are higher for females compared to

males; 40% women and 20% men for depression

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 (not mania though)

Mood Disorders: Neurobiological Influences

• Neurotransmitter systems– Low Serotonin and its relation to other

neurotransmitters causes mood disorders– Permissive hypothesis – when serotonin is low, other

neurotransmitters are “permitted” to become dysregulated

Mood Disorders: Neurobiological Influences

• The endocrine system– Elevated cortisol damages the hippocampus and

prevents neurogenesis

• Sleep disturbance– Hallmark of most mood disorders– REM and depression– Insomnia and depression linked

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 (interpretation) of life events and mood

– Reciprocal-gene environment model– Relationship between stress and bipolar is also

strong

Mood Disorders: Psychological Dimensions (Learned Helplessness)

Learned helplessness (LH)- Lack of perceived control over life events

• LH 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

Mood Disorders: Psychological Dimensions (Beck’s 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, the world and the

future – Negative schema

Mood Disorders: Social and Cultural Dimensions

• Marital relations– Marital dissatisfaction is strongly related to depression

especially in males

• Mood disorders in women– Females over males (70:30) except bipolar disorders

(50:50)– Gender imbalance likely due to socialization

(perceptions of uncontrollability)

• Social support– Extent of social support is related to depression and

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

Treatment of Mood Disorders: 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

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 enzyme that breaks

down serotonin and norepinephrine– Slightly more effective than tricyclics

• Must avoid foods containing tyramine– Examples include beer, red wine, cheese– Many patients do not like the dietary restrictions

Treatment of Mood Disorders: Tricyclic Antidepressants

• Used to be 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 so not good

for suicidal tendencies

Treatment of Mood Disorders: Lithium

• Lithium carbonate is a common salt– Primary drug of choice for bipolar disorders (50%

reduction in symptoms)– 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– Side effects are few and include short-term memory loss– Uncertain why ECT works– Relapse is common (60%)

Psychosocial Treatments

• Cognitive-behavioral therapy– Addresses cognitive errors in thinking– Also includes behavioral components

• Interpersonal psychotherapy– Identifies stressors and focuses on problematic

interpersonal relationships • Prevention• Combined treatments for depression more effective

(73% versus 48%)• Prevention relapse of depression• Psychosocial treatments for bipolar

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 (more females)Suicidal ideation - thinking seriously about suicideSuicidal plan – formulation of a specific methodSuicidal attempt – person survives

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/Pages/MoodDisorders.aspx