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Mood Disorders and Suicide
SymptomsDiagnosis
Course and OutcomeFrequency
CausesTreatment
Suicide
CHAPTER Five
Major depression is the leading cause of disability worldwide.
Depression accounts for 10% of all disability.
Affect: pattern of observable behaviors Facial expression, pitch of voice, body
movements Mood: a pervasive and sustained emotional
response that can color perception.
OVERVIEW
Mood disorders are defined in terms of episodes- discrete periods of time in which the person’s behavior is dominated by either a depressed or manic mood.
DSM-IV-TR defines 3 mood episodes.1. Major depressive episode
2. Manic episode3. Hypomanic episode
OVERVIEW
The 3 mood episodes form the basis of the 5 mood disorders:
Unipolar disorders – individual experiences only abnormally low moods (major depression, dysthymia).
Bipolar disorders – individual experiences both abnormally low and high moods (Bipolar I, Bipolar II, cyclothymia).
Depression Mania
Overview
Mood Episodes
Mood Episodes
Mood DisordersHypomanic episode - a less extreme
version of a manic episode that is not severe enough to significantly interfere with functioning.
The DSM-IV-TR Mood Disorders1) Major depressive disorder
One or more major depressive episode(s)No history of manic or hypomanic episodesSubtypes
Catatonic FeaturesPsychotic FeaturesMelancholic FeaturesPostpartum OnsetSeasonal Pattern
The DSM-IV-TR Mood Disorders
2) Dysthymic Disorder: Two years or more of consistently depressed mood and other symptoms that are not severe enough to meet criteria for a major depressive episode.
The DSM-IV-TR Mood Disorders3) Bipolar I disorder
Combination of major depressive episodes and manic episodes.
4) Bipolar II disorder Combination of major
depressive episodes & hypomanic episodes.
The DSM-IV-TR Mood Disorders
5) Cyclothymic disorder Two years or more of consistent mood swings between hypomanic highs and dysthymic lows.
Unipolar DisordersAverage age of onset = 32 but impacts
ALL age groups. Length of episodes vary widelyRelapse: a return of active symptomsApproximately ½ patients with MDD
recover in 6 months
COURSE AND OUTCOME
FIGURE 5-1 The Course and Outcome of Major Depression
Bipolar DisordersOnset usually occurs between 18 and 22
years.First onset can be depression or mania.Average duration of a manic episode
runs between 2 and 3 months.Long-term prognosis mixedRapid Cyclers—experiencing at least 4
mood episodes within a 12 month period
COURSE AND OUTCOME
Incidence and Prevalence16% of NSC-R study (n = 9,000)
suffered from depression.Lifetime risk of for bipolar I and II
disorders combined is close to 4%.Ratio of unipolar to bipolar disorders is
at least 5:1.
FREQUENCY
Gender Differences♀ 2-3x more vulnerable to depression
than ♂.♀ are more likely than ♂ to present
for mental health services.More difficult for ♂ to admit to
subjective feelings of distress.Gender differences not typically
observed for bipolar mood disorders.
FREQUENCY
Major losses of important people or rolesseem to play a crucial role in precipitating major depression.
Depression more likely when life events are associated with feelings of humiliation, entrapment and defeat.
Do negative life events cause depression? Or does depression lead to negative events?
Social Factors and Bipolar Disorders
Less attention paid to bipolar disordersWeeks preceding the onset of a manic
episode marked by an increased frequency stressful life events.
Factors different than from depressionSchedule-disrupting eventsGoal attainment
CAUSES
Psychological Factors: Cognitive vulnerabilityAaron Beck – pervasive and persistent negative thoughts central in the onset of depression when activated by a negative event.
Cognitive TriadLearned helplessness—Seligman
CAUSES
Cognitive Distortions
Response Styles and GenderRuminative style (women more likely) Distracting Style (men more likely)
Interpersonal Factors and Social BehaviorsSome depressed people create difficult
circumstances, increase the level of stress. Integration of Cognitive and Interpersonal
FactorsVulnerability to depression influenced by
childhood experiences.
Why do some people become depressed after stressful life events while others do not?
GeneticsTwin Studies
Genes play a more important role in bipolar disorders
Heritability (0–100): bipolar mood disorders have heritability of 80%
PolygenicGenetic Risk and Sensitivity to Stress
Gender, “s” allele of the 5-HTT—NO LONGER CITED AS DEFINITIVE
BIOLOGICAL FACTORS
The Hypothalamic- Pituitary-Adrenal (HPA) Axis is activated in response to stress.
FIGURE 5-5
Brain regions involved in emotions and mood disorders
FIGURE 5-6
NeurotransmittersMore than 100 different
neurotransmitters in the CNS, and each is associated with several types of postsynaptic receptors.
The 3 most likely to play a role in depression are: Serotonin, Norepinephrine, & Dopamine
BIOLOGICAL FACTORS
Cognitive therapyCognitive
restructuringFocuses on helping
patients replace self-defeating thoughts with more rational statements.
Focuses on current relationships, especially familial
Attempts to improve relationships by building communi-cation & problem-solving skills.
TREATMENT: UNIPOLAR DISORDERS
Interpersonal therapy
Unipolar Disorders - Antidepressant MedicationsFour general categories
Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSNRIs), Tricyclics, Monoamine Oxidase Inhibitors (MOA-Is)
Improvement typically four to six weeksCurrent episode often resolved within
12 weeks.Efficacy – only ~ 50%
TREATMENT
SSRI’s Block reuptake of
Serotonin Prozac, Paxil, Zoloft Most frequently used Easier to use Fewer side effects
Sexual dysfunction, weight gain
Less dangerous in event of overdose
Block reuptake of norepinephrine
Imipramine and amitripyline
More side effects:Constipation,
drowsiness, drop in BP, blurred vision
Equal in efficacy as SSRIs
TREATMENT: UNIPOLAR DISORDERS
Tricyclics
SSNRI’s
Effexor, CymbaltaBlock reuptake of
both serotonin and norepinephrine
Long term effects less known
TREATMENT: UNIPOLAR DISORDERS
MAO-I:
Phenelzine (Nardil) Not as effective
tricyclics Side effects:
Consuming foods with tyramine (cheese and chocolate) often increases BP.
Used in treatment of anxiety disorders, particularly agoraphobia and panic.
Electroconvulsive therapy (ECT)
Electromagnetic TreatmentsDeep brain stimulation
Experimental & Alternative Treatments
Lithium
Effective treatment in alleviation of manic symptoms
60% of patients improve
Non-compliance with drug due to side effectsNauseaWeight gainMemory problems
Mood StabilizersDepakot, TegetrolMechanism of how it
works is unknown
TREATMENT: BIPOLAR DISORDERS
Anti Seizure medications
Psychotherapy
Can be effective supplement to biological intervention
Combination of psychotherapy and medication is more beneficial than medication alone.
TREATMENT: BIPOLAR DISORDERS
15 to 20% of all patients with mood disorders will eventually kill themselves.
SUICIDE
SuicideS -- SexA -- AgeD -- Depression
P – Previous Attempt
E – Ethanol AbuseR – Rational ThoughtS – Social SupportO – Organized PlanN – No SpouseS -- Sickness
Classification of SuicideNonsuicidal Self-Injury
Deliberate self-harm without desire for suicide: cutting, burning, scratching the skin
Pain serves as useful purposeTo punish the selfIs a reflection of frustration and
anger.Maladaptive way to regulate
intense, negative emotional states.
SUICIDE
Causes of SuicidePsychological Factors
Psychological pain: social isolation, feelings of being a burden, previous attempts
Biological FactorsReduced levels of serotonin: poor
impulse control; violent and aggressive behaviors
Potential for genetic predispositionSocial Factors
Availability of guns, media
SUICIDE
Treatment of Suicidal PeopleCrisis Centers and Hotlines
Primarily suicide preventionEfficacy for “saving lives” not
demonstratedPeople with most lethal ideations will
not callOffers valuable assistance to people in
distressPsychotherapy
Reduce lethality
SUICIDE
Treatment of Suicidal PeoplePsychotherapy (continued)
Negotiate agreementsProvide supportReplace tunnel vision with a broader
perspectiveMedication
SSRIs in treating depression lowers suicide rates.
SUICIDE