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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
Dysthymic Disorder Milder symptoms 2+ years Chronic Persistent
Depressive Disorders: An Overview
Onset = early 20’s Early onset = before 21
Greater chronicity Poor prognosis Stronger familial component
Median duration = 5 years Depends on comorbidity
Dysthymic Disorder
Dysthymic Disorder
Double Depression Major depressive episodes and dysthymic
disorder Dysthymia first Severe psychopathology Poor course High recurrence rates
Depressive Disorders: An Overview
Depression frequently follows loss 62% after death
Pathological or Complicated Grief Severity of symptoms Dysfunction Persistence of symptoms
Grief and Depression
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
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
Additional Defining Criteria
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
Prevalence of Mood Disorders
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
Overlap of Anxiety and Depression
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
Causes of Mood Disorders : Biological
Shared genetic vulnerability High familial heritability Same genetic factors General predisposition
Except mania?
Depression and Anxiety: The Same Genes?
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 : Biological
Stressful life events Context Meaning Timing
Effects of stress Poorer treatment response Delayed remission Trigger for episode or relapse
Causes of Mood Disorders : Psychological
Reciprocal-gene environment model Stress triggers depression Depressed individuals create or seek out
stressful situations
Interaction with vulnerability Genetic Psychological
Causes of Mood Disorders : Stress
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
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
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 : Antidepressant Medications
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
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: ECT
Transcranial magnetic stimulation Localized electromagnetic pulse Fewer side effects Efficacy is likely good
More studies needed
Treatment of Mood Disorders: TMS
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