Chapter 6 Mood Disorders and Suicide
Dec 28, 2015
Range of Emotions
• A person with a mood disorder experiences emotions that are extreme and, therefore, abnormal.
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
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