Mood Disorders

The experience of depression or mania, either alone or in combination, is a feature of all mood disorders.

DSM-IV-TR criteria for a major depressive episode include:

a. Extremely depressed mood state lasting at least 2 weeks.b. Cognitive symptoms (e.g., feeling worthless, indecisiveness).c. Disturbed physical functions (e.g., altered sleep patterns, changes in appetite/weight, loss of energy) often referred to as somatic or vegetative symptoms. Such symptoms are central to this disorder.d. Anhedonia, or the loss of interest or pleasure in usual activities.

Average duration of an untreated major depressive episode is 4 to 9 months.

Mania refers to abnormally exaggerated elation, joy, or euphoria. Such episodes are accompanied by extraordinary activity (i.e., hyperactivity), require decreased need for sleep, and may include grandiose plans (i.e., believing that one can accomplish anything). Speech is typically rapid and may become incoherent, and may involve a ‘flight of ideas’ (i.e., attempt to express many ideas at once).

A hypomanic (hypo means below) episode is a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning.

DSM-IV-TR criteria for a manic episode include:

a. A duration of 1 week; less if the episode is severe enough to require hospitalisation.b. Irritability often accompanies the manic episode toward the end of its duration.c. Anxiousness and depression are often part of a manic episode.d. Inflated self esteem or grandiosity.

Average duration of an untreated manic episode is 3-6 months.

The structure of mood disorders

1. Unipolar disorder refers to the experience of either depression or mania, and most individuals with this condition suffer from unipolar depression. Bipolar disorder refers to alternations between depression and mania. 2. Feeling depression and mania at the same time is referred to as a dysphoric manic or mixed episode. In these episodes, patients usually feel as if their mania is out of control, and become anxious or depressed regarding this experience. A recent study indicated that 30% of patients hospitalised for acute mania actually had mixed episodes.3. Almost all major depressive episodes remit without treatment. Manic episodes remit without treatment after about six months. It is important to determine the course

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or temporal pattern of the depressive and manic episodes. Different patterns appear in the DSM-IV-TR under the heading ‘course modifiers for mood disorders’.

Course modifiers characterise the past mood state and are helpful to predict the future course of the disorder. Understanding the course is related to predicting future occurrences of mood changes and in helping to prevent them.

Depressive disorder

1. Major depressive disorder, single episode is defined, in part, by the absence of manic or hypomanic episodes before or during the episode. The occurrence of one isolated depressive episode in a lifetime is rare, and unipolar depression is almost always a chronic condition that waxes and wanes over time, but seldom disappears.

2. Major depressive disorder, recurrent requires that two or more major depressive episodes occur and are separated by a period of at least 2 months during which the individual is not depressed. About 85% of single-episode cases later have a second episode of major depression.

The median lifetime number of major depressive episodes is four, and the median duration is 4 to 5 months.

3. Dysthymic disorder shares many of the symptoms of major depression, but unlike major depression, the symptoms in dysthymia tend to be milder and remain relatively unchanged over long periods of time, typically as much as 20 or 30 years. Dysthymic disorder is defined by persistently depressed mood that continues for at least 2 years. During this time, the person cannot be symptom-free for more than 2 months at a time.

The earlier it starts, the poorer the prognosis.

One 10-year study indicated that 22% of those suffering from dysthymia eventually experienced a major depressive episode.

4. Double depression refers to both major depressive episodes and dysthymic disorder. Dysthymic disorder often develops first, and this condition is associated with severe psychopathology and problematic future course. Indeed, many do not recover after two years, and relapse rates are very high.

The risk for developing depression is low until the early teens, when it begins to rise; the mean age of onset is 30. There is some evidence that the risk of developing depression while younger is on the increase (although this may be due to better recognition of depression in younger people).

Untreated depression does tend to remit, but residual symptoms may leave the individual vulnerable to later episodes. The phenomenon has been called 'kindling', as described by Kenneth Kendler and his colleagues, for example. They found that although a first episode of depression is usually caused by a severe adversity, the

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experience of one depressive episode makes a second more likely, the second makes a third yet more likely, and so on.

Scott Monroe and Kate Harkness (2005) have distinguished two ways in which kindling might work. One is that the depressive disposition might become autonomous, so that processes that trigger depression come to be internal rather than external.

The alternative is that kindling is a sensitisation process in which, with increasing experience of depression, progressively less severe adversities trigger each succeeding episode. These two explanations have not yet been distinguished by research.

One implication seems to be that more effort should be made to clear up residual symptoms of depression and not just accept a reduction in symptoms.

A kindling explanation has also been applied to Bipolar Disorder, but the findings are less clear, with several studies not finding evidence when they might have expected to. See http://bipolar.about.com/cs/brainchemistry/a/0102_kindling2.htm

The mean age of onset for dysthymia is typically in the early 20s (i.e., late onset). The onset of dysthymia before age 21 (i.e., early onset) is associated with (a) greater chronicity, (b) relatively poor prognosis (i.e., response to treatment), and (c) stronger likelihood of the disorder running in the family. The median duration of dysthymic disorder is approximately 5 years in adults and 4 years in children.

Patients suffering from dysthymia have a higher likelihood of attempting suicide than those suffering from major depressive disorder.

Double depression is common, with as many as 79% of people with dysthymia reporting a major depressive episode at some point in their lives.

The frequency of severe depression following the death of a loved one is quite high, at around 62%. Most mental health professionals do not consider depression associated with death or loss a disorder unless very severe symptoms appear (e.g., psychotic features, suicidal ideation, or the less-alarming symptoms that last longer than 2 months). Grief is usually resolved within several months post loss, but may be exacerbated at significant anniversaries, such as the birthday of the loved one or during holidays.

a. If grief lasts longer than 1 year or so, the chance of recovering from severe grief is greatly reduced and mental health professionals may become concerned.b. A history of major depressive episodes may predict the development of a pathological grief reaction or impacted grief reaction, which include symptoms of intrusive memories and strong yearnings for the loved one, and avoiding people and places associated with the loved one. Around 10-20% of bereaved individuals may experience this reaction, which is associated with suicidal thoughts, despite not having been depressed previously. Some theorists suggest that pathological grief be considered diagnostically distinct from major depression.

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c. Treatment of pathological grief involving finding meaning in the loss, incorporating positive emotions into the grief and finding ways to cope show better outcomes than interpersonal therapy.

Bipolar disorders

1. The core, identifying feature of bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes. Beyond that, bipolar disorders parallel depressive disorders (e.g., a manic episode can occur once or repeatedly).

2. Bipolar I disorder is the alternation of full manic episodes and depressive episodes. a. Average age of onset is 18 years, but it can begin in childhood.b. Tends to be chronic.c. Suicide attempts are estimated to occur in 17% of patients, usually in a depressive episode.

A study reported in 2010 by Solomon and colleagues found that that, for patients with Bipolar I disorder, the median duration for any type of mood episode - either mania or depression - was 13 weeks.

3. In bipolar II disorder, major depressive episodes alternate with hypomanic episodes. a. Average age of onset is 19-22 years, but it can begin in childhood.b. Only 10 to 13% of cases progress to full bipolar I disorder.c. Tends to be chronic.d. Suicide attempt rates are estimated at 24%.

4. Although major depression and bipolar disorder were once thought to be distinct conditions, some studies have indicated that about 25% of depressed individuals may go on to experience a full manic episode, with over two-thirds of depressed individuals endorsing some manic symptoms. Thus, these conditions may be best described as existing on a continuum.

5. Completed suicide in bipolar disorder is 4 times more common than in recurrent major depression. Long-term studies show completed suicide rates of 8-11% in bipolar disorder.

A recent study (Zimmerman, Ruggero, Chelminski, & Young, 2009) suggests that there are problems with the Diagnosis of Bipolar Disorder. An earlier study found that 57% of those diagnosed with Bipolar Disorder had been misdiagnosed. The Zimmerman study looked at what disorders they actually had, using the SCID structured interview. They found that nearly half had major depression, while borderline personality disorder, post-traumatic stress disorder (PTSD), generalised anxiety and social phobia occurred in roughly one-quarter to one-third.

One of the reasons why this is a problem is because the mood stabilising drugs given to Bipolar patients have significant side effects. Another problem is that they are not

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receiving the treatment they do need. The lead author thinks that people are diagnosing conditions that they know how to treat.

6. Cyclothymic disorder is a more chronic version of bipolar disorder where manic and major depressive episodes are less severe. Such people tend to remain in either a manic or depressive mood state for several years with very few periods of neutral (or euthymic) mood. For the diagnosis, the pattern must last for at least 2 years (1 year for children and adolescents). Such people are also at increased risk for developing bipolar I or II disorder.

a. Average age of onset is about 12 or 14 years.b. Cyclothymia tends to be chronic and lifelong.c. Most are female.

Additional defining criteria for mood disorders or subtypes of depression

Symptom specifiers can be helpful in determining the most effective treatment and are of two broad types: those that describe the most recent episode of the disorder, and those that describe its time course or temporal pattern.

Those related to the most recent episode are:

Atypical (Oversleep, overeat, gain weight, anxious) Melancholic (severe, anhedonia and possible weight loss) Chronic (major depression lasting at least 2 years) Catatonic (absence of movement – very serious) (with mania, the movements

are bizarre or purposeless) Psychotic (Mood congruent/ incongruent) Postpartum (may experience manic or depressive episodes)

Examples of the subtypes related to the time course are:

Full recovery versus left with residual symptoms Rapid cycling Seasonal Affective Disorder (SAD)

SAD is usually associated with lower levels of sunlight in the extreme latitudes.

Some behaviour observed during Australia’s Top End ‘build up’ is acknowledged by some to be a form of SAD (sometimes known in this area as ‘Mango Madness’ or ‘Going Troppo’).

DR Petros Markou, Psychiatrist/Psychotherapist: “It probably means things such as becoming a little more depressed, becoming more angry, becoming more irritable, becoming more clumsy even, perhaps.”

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Rates of violence and alcohol consumption rise during the Build Up, according to doctors at the Royal Darwin Hospital.

Prevalence is about 1% of the adult population for light-related SAD.

Postpartum Depression

Prevalence is between about 1 and 10% of births. A paper published in 2010 by Julia Sacher and colleagues of Leipzig have located a plausible biological trigger for this. It has been known for some time that there is a rapid fall in the level of oestrogen after birth. Sacher’s team found that this coincided with an increase in monoamine oxidase A (MOA) in the brain. This enzyme breaks down both serotonin and dopamine, neurotransmitters that are associated with contentment. Low levels of these may trigger depression. Levels of MOA peak at about 5 days after birth, the time new mothers often hit their lowest point. This study suggests that drugs that inhibit MOA may prevent or treat postnatal depression.

Variation in the appearance of depression

Some researchers think that depression does not have the same appearance in all groups – that the classic DSM-IV signs and symptoms are mainly the pattern seen in adult, western women.

Younger children may have different signs, for example. Preschoolers may not show persistent symptoms, but have bouts of sadness interspersed with periods of normal behaviour. One feature of depression - a loss of interest in things a person once enjoyed - appears to be the strongest sign of major depression in young children. This is still a controversial diagnosis though.

According to William Pollack, director of the Centers for Men and Young Men at McLean Hospital in Boston, depressed men are more likely to behave recklessly, drink heavily or take drugs, drive fast and/or express anger. Pollack believes that the differences in appearance lead to men being less likely to be diagnosed with depression, which may be one of the reasons they are four times more likely to die by suicide than women.

Prevalence of Mood Disorders

A. About 13-16.6% of individuals experience some type of mood disorder during their lifetimes, with 5.2-6.7% in the past year. Females are twice as likely to be diagnosed with a mood disorder compared to males. The imbalance between males and females is accounted for largely by major depressive disorder and dysthymia.

Bipolar disorders, apart from cyclothymia, are distributed equally between males and females.

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B. Estimates of the prevalence of mood disorders in children and adolescents vary widely. The consensus is that depressive disorder occurs less often in children than adults but that this difference closes somewhat during adolescence, where depression becomes more frequent compared to adults. Children less than 9 years of age show more irritability and emotional swings rather than classic manic states, and are often mistaken as hyperactive. Bipolar disorder is rare in childhood, but rises substantially in adolescence, as does suicide.

C. As many as 18% to 20% of elderly nursing home residents may experience major depressive episodes, which are likely to be chronic. It is difficult to diagnose depression in the elderly due to medical illnesses and symptoms of dementia. Generally, the prevalence of major depressive disorder in the elderly is about half that in the general population. Anxiety disorders more often accompany depression in the elderly. Menopause may increase rates of depression among women who have never previously been depressed, which may be due to biological factors or life changes.

The gender imbalance in depression disappears after age 65.

From those who take an evolutionary perspective on the mental disorders there is some speculation that there may be a connection between depression and creativity.

Co-Morbidity

Most people who are depressed are also anxious, whereas not all those who are anxious are depressed.

Causes of Mood Disorders

Biological dimensions

1. Family studies indicate that the rate of mood disorders in relatives of probands (i.e., the person known to have the disorder) with mood disorders is generally two to three times greater than the rate in relatives of people without the disorder. The most frequent mood disorder in relatives of people suffering from mood disorders is unipolar depression.

2. Twin studies reveal that if one identical twin presents with a mood disorder, the other twin is 3 times more likely than a fraternal (non-identical) twin to have a mood disorder, particularly for bipolar disorder. Severe mood disorders may have a stronger genetic contribution than less severe disorders. There also appear to be sex differences in genetic vulnerability to depression, with heritability rates being higher for females compared to males. The environment appears to play a larger role in causing depression in males than females.

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Twin studies also support the contention that unipolar and bipolar disorder are inherited separately. Studies now indicate the contribution of a small group of genes that explain heritability of some types of depression.

3. Data from family and twin studies also suggest that the biological vulnerability for mood disorders may reflect a more general vulnerability for anxiety disorders as well.

4. Many reports implicate neurotransmitter systems in the aetiology of depression. Research implicates low levels of serotonin as a factor in mood disorders but only in relation to other neurotransmitters, including norepinephrine and dopamine. One of the functions of serotonin is to regulate systems involving norepinephrine and dopamine. The permissive hypothesis says that when serotonin levels are low, other neurotransmitters are permitted to range more widely, become dysregulated, and contribute to mood irregularities.

Dopamine is more involved in mania.

5. Another theory of depression has implicated the endocrine system, particularly elevated levels of cortisol. Cortisol and other neurohormones are a key focus of study in psychopathology. This area of research has led to the controversial dexamethasone suppression test (DST). Dexamethasone is a glucocorticoid that suppresses cortisol secretion. As many as 50% of those with depression, when given dexamethasone, show less suppression of cortisol. However, people with anxiety disorders also demonstrate nonsuppression.

New research findings indicate that elevated levels of stress hormones in the long term may interfere with the production of new neurons (i.e., neurogenesis), especially in the hippocampus, which may result in disrupted memory processes.

6. Sleep disturbances are a hallmark of most mood disorders. Depressed people move into the period of rapid eye movement sleep (REM) more quickly than non-depressed people and also show diminished slow wave sleep (i.e., the deepest and most restful part of sleep). This REM effect is reduced for people who have depression related to recent life stress. REM activity is intense in depressed people. Depriving depressed people of sleep improves their depression. People with bipolar disorder and their children show increased sensitivity to light (i.e., greater suppression of melatonin when exposed to light at night). A relationship between seasonal affective disorder, sleep disturbance, and disturbance in biological rhythms has thus been proposed.

Brain wave activity

Different alpha electroencephalogram (EEG) values have been reported in the two hemispheres of brains of depressed people. Depressed people show greater right-side anterior activation of the cerebral hemispheres (i.e., less left-side activation and less alpha wave activity) than non-depressed people. This type of brain function may be an

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indicator of a biological vulnerability for depression, as it is seen in adolescent offspring of depressed mothers.

Psychological dimensions

1. Stressful and traumatic events influence mood disorders, although the context, meaning, and memory of an event must be considered. A relationship has been found between severe life events, onset of depression, poorer response to treatment, and longer time before remission.

Some studies have found that jetlag can trigger a bipolar episode.

New research suggests that one-third of the association between stressful life events and depression is due to a vulnerability whereby depressed people place themselves in high-risk stressful situations (i.e., reciprocal gene-environment model). In addition, stressful life events and circadian rhythm disturbances may trigger manic episodes. However, only a minority of people experiencing a negative life event develop a mood disorder; therefore, interaction with a biological vulnerability is likely.

2. According to Martin Seligman’s learned helplessness theory of depression, people develop depression and anxiety when they assume they have no control over life stress. A depressive attributional style has the following three characteristics: a. First, the attribution is internal in that the person believes negative events are their fault. b. Second, the attribution is stable in that the person believes the situation will continue into the foreseeable future. c. Third, the attribution is global in that the person believes negative events will influence many life activities.

3. Studies indicate that negative cognitive styles precede, and thereby may operate as a risk factor for, depression.

4. Attributions are important as a vulnerability that contributes to a sense of hopelessness; a feature that distinguishes depressed from anxious individuals.

5. Aaron Beck, the founder of Cognitive Therapy, proposed that depression results from a tendency to interpret life events in a negative way. People with depression often engage in several cognitive errors and think the worst of everything. The following examples of cognitive errors are illustrated in the textbook:a. Depressed people to emphasise the negative rather than positive aspects of a situation.b. They also have a tendency to take one negative consequence of some event and generalise to all related aspects of the situation.

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6. According to Beck, people with depression consistently make such cognitive errors, as represented in thinking negatively about themselves, their immediate world, and their future (called the depressive cognitive triad). These beliefs may comprise a negative schema, or an automatic and enduring cognitive bias about aspects of life. Substantial empirical evidence supports this theory, as those of you who have taken PSY390 will know.

7. Current integrative models of cognitive vulnerability for depression implicate both learned helplessness and negative cognitive styles as risk factors for depression. One study has demonstrated that negative cognitive styles do confer vulnerability for later depression.

Social and cultural dimensions

1. Marital dissatisfaction and depression are strongly related, and marital disruption often precedes depression. This seems particularly true for men. In addition, high marital conflict and/or low marital support are important in the aetiology and recurrence of depression. Conversely, continuing depression may lead to the deterioration of a marital relationship.

2. Gender imbalances occur across the mood disorders (with the exception of bipolar disorder) and this is a world-wide phenomenon. Around 70% of people with major depressive disorder and dysthymia are women.

The figures for Major Depression in Australia in a study by Wilhelm in 2003 were 2.3% for males and 3.9% for females.

3. The number and frequency of social relationships and contact may be related to depression. A lack of social support appears to predict the later onset of depressive symptoms, and high expressed emotion (patterns of interaction characterised by criticism, blame, and conflict) or dysfunctional families may predict relapse. Conversely, substantial social support is related to rapid recovery from depression.

An integrative theory of the aetiology of mood disorders

1. Depression and anxiety may share common biological/genetic vulnerabilities, such as an overactive neurobiological response to stressful life events.

2. Psychological vulnerabilities, such as attributions, correlate highly with biochemical markers. Childhood adversity and exposure to depressed caregivers may be related to the later development of mood disorders.

3. The onset of stressful life events may then activate stress hormones that affect certain neurotransmitter systems, including turning on certain genes. Extended stress may also affect circadian rhythms and activate a dormant psychological vulnerability characterized by negative thinking and a sense of helplessness and hopelessness.

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4. In addition, psychological vulnerabilities such as feelings of uncontrollability may be triggered. All of this is dependent, however, on mediating environmental factors such as interpersonal relationships.

Treatment of mood disorders

Three main types of antidepressant medications are used to treat depressive disorders:

1. Tricyclic antidepressants are still widely used treatments for depression, and include imipramine (Tofranil) and amitriptyline (Elavil). It is not yet clear how these drugs work, but initially at least they block the reuptake of norepinephrine and other neurotransmitters (i.e., down-regulation of the post-synaptic receptors). This process may take anywhere between 2 to 8 weeks, and patients often feel worse and develop side-effects before feeling better. Side-effects include blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain, and sexual dysfunction. Because of the side-effects, about 40% of patients stop taking the drugs. Tricyclics alleviate, but do not eliminate, depression in 50% of cases compared to 25-30% of people taking placebo. Tricyclics may be lethal in excessive doses.

2. Monoamine oxidase inhibitors (MAOI) work by blocking an enzyme monoamine oxidase that breaks down serotonin and norepinephrine. MAO inhibitors are slightly more effective than tricyclics and have fewer side-effects. However, eating tyramine foods (e.g., cheese, red wine, beer) or cold medications with the drug can lead to severe hypertensive episodes and occasionally death. New MAO inhibitors are more selective, short acting, and do not interact negatively with tyramine. Use of MAO inhibitors has decreased significantly in recent years.

3. Selective serotonin reuptake inhibitors (SSRIs) specifically block the pre-synaptic reuptake of serotonin, thus increasing levels of serotonin at the receptor site. Fluoxetine (Prozac) is the best known SSRI, although Sertraline (Zoloft) is probably prescribed most often. Risks of suicide or acts of violence are no greater with Prozac than with any other antidepressant medication in adults. In adolescents, the data are mixed regarding whether or not SSRIs are related to suicidality. It is possible that SSRIs confer an initial risk of suicidal thoughts (in the first few weeks), but later are related to decreased suicidality.

The U.S. Food and Drug Administration carried out a review of 372 trials involving nearly 100,000 people who took antidepressants. It showed that the drugs increase the risk for suicide in people younger than 25, have no effect in those 25 to 64 and reduce risk in those 65 and older. A report on the findings was published online Aug. 12 in the British Medical Journal. It has been criticised by academics who say that it under-estimates the suicide risk because the most severely depressed people were excluded from the trials.

Common side-effects of Prozac are physical agitation, sexual dysfunction or low desire, insomnia, and gastrointestinal upset.

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Newer antidepressants, such as Venlafaxine and Nefazodone work on slightly different mechanisms than other SSRIs, and are comparable to effectiveness of older antidepressants.

St. John's Wort (hypericum) is receiving attention as an herbal solution for depression. Preliminary studies suggested that St. John's Wort works better than placebo in alleviating depression and works as well as low doses of other antidepressant medications, although one recent NIH study found no benefit of the drug. St. John's Wort also appears to alter serotonin function and has few side-effects.

A recent study indicated that there is some benefit of switching from one medication to another in cases of persistent depression, with some people benefiting from the change to a second drug or addition of a second drug.

Current studies indicate that these drug treatments are effective with adults, but not necessarily with children, and may cause substantial negative side-effects in children. Similar concerns are evident for the elderly population. Overall, recovery from depression may not be as important in treatment as preventing the next episode of depression from occurring. Drug treatment is typically extended well past the end of a patient's current depressive episode.

It is important to note that approximately 30% of depressed people do not respond to these medications, and females of childbearing age must avoid conceiving while taking antidepressants.

The benefits of SSRIs often require three to four weeks to become apparent, so critical days pass before the success of the prescription can be determined.

Thus the discovery of treatments with a more rapid onset is a goal of biological psychiatry. The first drug found to produce rapid improvement in mood was the NMDA glutamate receptor antagonist, ketamine (used as an anaesthetic). However, Furey and Drevets (2006) report that another medication, scopolamine, also appears to produce replicable rapid improvement in mood. Scopolamine temporarily blocks the muscarinic cholinergic receptor, thought to be overactive in people suffering from depression.

In a DB RC study, Scopolamine was found to reduce symptoms of depression within three days of the first administration. Half of participants experienced full symptom remission by the end of the treatment period and the antidepressant effect persisted for at least two weeks without further treatment.

The efficacy of scopolamine is interesting because the blocking of muscarinic receptors was a property of tricyclic medications. With these medications, the muscarinic receptor blockade was mostly viewed as the cause of unwanted side effects, such as constipation, sedation, and memory impairments.

Newer antidepressants, such as SSRIs or SNRIs, were explicitly designed to avoid blocking muscarinic receptors. Yet, these data raise the possibility that this strategy may have increased the tolerability of these medications at the expense of providing effective and timely relief.

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However, in a small-scale study with too many authors to name (18 participants and 13 authors!), ketamine was found to lift the mood of depressed bipolar patients who had previously tried seven anti-depressants on average plus ECT, within 40 minutes of administration (Arch Gen Psychiatry. 2010;67(8):793-802. doi:10.1001/archgenpsychiatry.2010.90). Seventy one percent of the participants responded, compared to 6% given the placebo.

Lithium is a common salt found in the natural environment, including drinking water. Lithium has historically been the primary drug of choice in the treatment of bipolar disorder. Side-effects may be severe, and dosage must be carefully regulated to prevent toxicity (poisoning) and lowered thyroid functioning. Substantial weight gain is also a common side-effect. Debate exists as to how lithium works, but possibilities include the reduction of dopamine and norepinephrine or changes in neurohormones. About 30-60% of people with bipolar disorder respond well to lithium treatment.

In other cases of bipolar disorder, anti-seizure medication may be effective. Valproate, an anticonvulsant has recently overtaken lithium as the most frequently prescribed mood stabiliser, and is equally effective in reducing mood cycling, though it does not prevent suicide as well as lithium.

Regardless of the actual drug used for treatment of bipolar disorder, many patients are noncompliant or discontinue their medications, possibly because of the “high” many experience during manic states.

Electroconvulsive therapy (ECT) is the treatment of choice for very severe, unresponsive depression. The patient is anesthetised and is given muscle-relaxing drugs to prevent bone breaks from convulsions during seizures and is then given a brief (less than 1 second) electric shock to the brain. The result is convulsions lasting for several minutes. Treatments are usually administered once every other day for a total of 6 to 10 treatments.

Side-effects are few and are limited to short-term memory loss and confusion, both of which usually disappear after a week or two. Approximately 50% of people not responding to medication benefit from ECT. However, relapse is extremely common, necessitating follow-up with antidepressant drugs. The mechanism of action for ECT is unclear.

Transcranial magnetic stimulation (TMS) is a new procedure that is related to ECT, but involves setting up a strong magnetic field around the brain. Mixed data exist regarding whether TMS is superior to ECT.

Some non-drug biological approaches are also in development, such as implanting a transmitter that stimulates the vagus nerve, thought to influence neurotransmitter production. Deep brain stimulation via electrodes in the limbic system is also a possible approach. Both of these treatments are for treatment-resistant depression.

At least three major psychosocial treatments are available for depressive disorders.

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1. Aaron Beck's cognitive therapy involves teaching clients to examine the types of thinking processes they engage in while depressed and recognize cognitive errors when they occur. Clients are informed about how these processes lead to depression and faulty thinking patterns are modified. Clients also monitor and record their thoughts between therapy sessions and are assigned homework to change their behaviour. Increased behavioural activity to elicit social reinforcement and to test hypotheses about the world is also used. Treatment usually takes 10 to 20 sessions.

2. Lewinson and Rehm developed a form of cognitive-behaviour therapy for depression that focused initially on reactivating depressed patients and countering their mood by bringing them in contact with reinforcing events. More recent approaches have also stressed the avoidance of social and environmental cues that produce negative affect or depression.

It is possible that increased activities alone may improve self-concept and lift depression, suggesting that the behavioural component of CBT may be the active ingredient of treatment.

3. Interpersonal therapy (IPT) focuses on resolving problems in existing relationships and/or building skills to develop new relationships. Like CBT approaches, IPT is highly structured and seldom takes longer than 15 to 20 weekly sessions. The therapist and client identify life stressors that precipitate depression, and then address interpersonal role disputes, adjustments to losing a relationship, acquisition of new relationships, and social skills deficits.

Recent studies comparing the results of cognitive therapy and IPT to those of tricyclic antidepressants and other control conditions for major depressive disorder and dysthymia have shown that psychosocial approaches and medication are equally effective, and that all treatments are better than placebo and brief psychodynamic therapy.

Current data suggest that combining medication and psychosocial treatments may provide an added benefit over providing each treatment alone. However, combining two treatments is expensive so a psychosocial treatment may be tried first before adding other options. Psychosocial interventions (i.e., cognitive therapy and IPT) seem helpful in preventing relapse. In a recent study, cognitive therapy showed an enduring effect over medication in preventing later recurrence of depression.

Though medication is the preferred treatment for bipolar disorder, most clinicians emphasise the need for psychosocial interventions to manage interpersonal and practical problems, particularly non-compliance with medication and family stress. These have been shown to be related to increased risk of relapse.

A relatively new approach called interpersonal and social rhythm therapy (IPSRT) focuses on helping patients to regulate their sleep cycles and schedules while also improving relationships. IPSRT has shown a benefit in reducing the frequency of manic and depressive episodes. Family therapy may also be beneficial for bipolar disorder.

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A critical viewpoint on antidepressant medication

Twenty years ago people thought of depression as an emotion related to feeling sad. To treat it, you had to find out why that person felt sad. Since then, drug companies have been influential in convincing people that depression is a medical disease and should be treated by drugs.

However, when you start looking at recent research (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008), you find that these drugs may have little effect. You can find individuals who will say that antidepressants are wonderful. That could be a placebo effect, however.

If a person is very unhappy, and it goes on for months, that probably means there's something seriously wrong in that person's life. It's not for trivial reasons. It is probably not going to be easy to change that.

Some drugs will provide symptomatic relief and there are times when symptomatic relief can be important. So there should be a respectable, but small place for the use of drugs in treating emotional disorders.

The problem is that sometimes psychiatrists prescribe a psychiatric medication for symptomatic relief and then lose sight of that fact that they are just relieving symptoms and think they are providing a cure, and the drugs can't do that. That scenario has been re-enacted several times in the history of psychiatry.

For about 10 years there has been research showing that antidepressants don't reduce the frequency of suicide. For some individuals the drug actually increases the suicide rate. Peter Breggin [the author of the 1990s bestseller Talking Back to Prozac] says that in some cases people are very despondent, and then they are given a drug that artificially makes them more energetic - that's not a good combination.

I think that the main thing that prevents people from suicide is not a drug - it is having a relationship with someone who really cares about them.

Having said all that, I am aware of one survey carried out in the USA in 2010 by Consumer Reports magazine that said that 80% of the respondents preferred to take a pill than a talking therapy.

Suicide

According to the WHO, every 40 seconds someone in the world dies by suicide. Every 3 seconds someone attempts it. On a worldwide basis, more people die from suicide than wars or murders.

Definitions

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Suicide involves the intentional taking of one's life. The difficulty lies in determining this intent. Those contemplating suicide often aren't clear about their own intention.

Parasuicide refers to any non-accidental act of self-injury that does not result in death. This definition has the benefit that we do not have to make assumptions about intention, which we do if we use the phrase ‘attempted suicide’.

Prevalence

According to the ABS, for Australian men as a whole, suicide fell by 6% between 2002 and 2003 to 17.7 per 100,000. This was 24% lower than the peak year of 1997. The rate dropped further to 16.3 by 2005, the latest year for which I could obtain comparable figures.

The figure for females for 2003 (4.7 per 100,000) was the lowest since 1994. It dropped further to 4.3 by 2005. The highest rate for both males and females occurred around the age of 30-34. Australian men over the age of 75 are about 5 times more likely to die by suicide than women of that age.

The NT has the highest rate of the states and territories (23.6 per 100,000) because of its relatively high proportion of ATSI.

The rate for Australian Aboriginal males aged 15-19 between 1993 and 1995 was very high at 75 (Harrison, Moller, & Bordeaux, 1997).

Government statistics in most countries underestimate the true suicide rate. Some coroners are unwilling to record a verdict of suicide because of pressures from the family of the deceased. Coroners also find it difficult to ascertain intent and some will require different amounts of evidence of intent than others. Differences in reporting between nations make comparisons difficult, although immigrant studies may reveal national differences.

Within Europe the highest rate is in Hungary (41.85) and the lowest Spain (6.6). Southern Europe is generally lower than northern and eastern Europe. This pattern also holds true for immigrants to Australia.

Being single, widowed, divorced or separated increases the risk of suicide compared to being married.

Suicide is more common amongst manual and semi-skilled labourers than among other occupational groups. However, some occupational groups in western nations are more vulnerable, including veterinarians, dentists and farmers. Having satisfying, productive work is associated with reduced risk and work-related problems are associated with increased risk.

How do people commit suicide?

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In Australia, the commonest method is hanging (45%) followed by poisoning, including the use of car exhaust (19%). Use of drugs is about 13% and use of firearms is 9%.

Men generally use more violent methods than women. In many parts of Europe, men choose hanging and women choose poisoning. In the USA, men choose handguns and women again choose poisoning. In Fiji and other parts of the Pacific Region, Paraquat (weed killer) and hanging are very common for both males and females. The methods used reflect the availability of options. Some people have preferred methods of killing themselves and if access to that is restricted they are less likely to kill themselves.

How do psychologists study suicide?

The main methods are:

Analysis of official suicide statistics Inquest papers and records Longitudinal cohort analysis Suicide note analysis Psychological autopsy Interviews with parasuicides and high risk groups Randomized controlled trials

Risk factors in suicide

Poor mental health has long been recognised as an important factor in suicide. Suicides and parasuicides share clinical characteristics that are different from others:

Depression - About 15% of depressed people will eventually take their own lives and about two thirds of all suicides have a depressive illness (Maris, 1991). This is higher than the figure given by Barlow and Durand (2008), which suggests a figure of up to 11%.

Family history Low serotonin levels Alcoholism - long term, rather than short term, alcoholism is a risk factor Substance abuse Anti-social behaviour Body dysmorphic disorder (BDD) substantially raises the risk Suicide risk is higher among those diagnosed with anorexia nervosa. Schizophrenia - about 10% of schizophrenics die by suicide. Personality disorder, particularly Borderline PD, raises the risk. Suicidal ideation High stress and PTSD Child abuse of all types - both abusers and the abused are at higher risk A history of self-harm or a previous suicide attempt Media coverage (sensationalising and describes the method)

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As many as 25% of adolescent suicides in Europe have a history of alcohol abuse. Substance abuse is a significant risk factor for this group.

For parasuicides, people with three or fewer of the factors in the following list had a 5% chance of repeating an attempt, while those with eight or more had a 41.5% chance:

Previous parasuicide Personality disorder High alcohol consumption History of psychiatric treatment Unemployment Unskilled labourer Drug abuse Criminal record Violence (in the previous 5 years) as victim or perpetrator Aged between 25 and 54 Single, widowed or divorced

Social Factors in Suicide

People who are isolated socially are more likely to kill themselves than those who are not. Inadequate social support is implicated in many psychological problems, as well as increased suicide risk.

People in rural areas are at greater risk than those in urban areas. In a study of rural suicides in Japan, Watanabe, Hasegawa & Yoshinaga (1995) found that the modern shift from extended to nuclear families and the dissolution of traditional family structures led to feelings of isolation and abandonment among older people.

In times of civil unrest, suicide rates may be lower, as in the 'Troubles' in Northern Ireland. It is thought that the unrest led to a greater feeling of community and solidarity, which buffered against suicide. The suicide rate rose as the unrest diminished, but has subsequently declined.

Prisoners have many of the risk factors for suicide and the likelihood of suicide or parasuicide is greatest shortly after admission in most countries.

Among females, higher suicide rates are associated with lower levels of religious belief. This is not seen among men.

I mentioned that people with satisfying, productive jobs are less likely to die by suicide. Unemployment is connected with increased suicide and parasuicide.

Although, under most circumstances, higher social support predicts favourable outcomes, including reduced suicidal ideation, there are some combinations of factors in which social support increases suicidal ideation. One study reported that people suffering depression, physical illness or unemployment, who receive social support,

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experienced more suicidal ideation (Brown & Vinokur, 2003). The critical factor seems to be the inability to reciprocate the support they receive. This leads them to feeling a burden - a very significant risk factor.

A study of 50 parasuicides found that they had experienced twice as many major life events as comparable non-parasuicides. Other studies found an increase in the frequency of negative life events in the month before a suicide attempt. Bereavement, divorce, separation and conflict are amongst the most frequently seen events. Also, suicide attempters have poorer social skills and poorer peer relationships than others.

Cultural Factors in Suicide

A comprehensive overview of youth suicide in Australia reported a rate of 75 per 100,000 for Aboriginal males aged 15-19 in SA, WA and NT between 1993 and 1995 (Harrison, Moller, & Bordeaux, 1997). This is comparable to the highest rates among young people anywhere in the world. The rate is even higher in Queensland. From 1990-95 the suicide rate for ATSI males between 15 and 24 was 112.5 per 100,000 (Baume, Cantor, & McTaggart, 1998).

Personal Factors in Suicide

In the biomedical model, suicide is caused by biological factors. For example, neurotransmitter imbalances cause mental illness, which in turn causes suicide. However, people may have a neurotransmitter imbalance and not attempt suicide.

In the biopsychosocial model, suicide is seen as the result of the interaction of biological, psychological and social factors. A personal factor such as impulsivity can interact with other predisposing factors to make a suicide attempt more likely.

In many cases, suicide should be seen not as an attempt to end their life, but as an attempt to end an unbearable psychological pain in someone who cannot see any other way of achieving that.

Aaron Beck, developer of Cognitive Therapy (1974), saw feelings of hopelessness as the mediator between depression and suicidal behaviour.

Parasuicide patients take longer to recall positive memories about their lives. They also recall more general memories about their lives, finding it too painful to recall specific memories.

Perfectionism, the setting of unrealistically high goals, is another predictor of suicidal behaviour. Perfectionists are overly concerned with the most minor of mistakes. They also doubt their own ability and tend to perceive a task as a failure if it includes a hint of a mistake. This may be linked to parental rearing style, where parental love was conditional on performance. Perfectionists are driven by the fear of failure rather than the desire for success.

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Those who consider themselves a burden to others are more likely to complete their suicide attempt and to use more lethal means in the process, according to Thomas Joiner of Florida State University in Tallahassee in a 2002 issue of the Journal of Social and Clinical Psychology.

Joiner and his colleagues rated 40 suicide notes left by people in the south western USA on the extent of feelings of burdensomeness, hopelessness, general emotional pain and other factors. Half of the notes were left by suicide completers, who were more often male, and half were left by people who did not complete their suicide attempt, most of whom were female.

The investigators found that suicide completers thought of themselves as more of a burden to others than did the attempters. The notes left by suicide completers more highly endorsed the idea that their loved ones would be better off after they were gone.

None of the other factors greatly differed between the suicide attempters and completers.

Joiner's team conducted a second analysis of notes left by 40 German men and women who committed suicide. They found that those who considered themselves a burden to their loved ones were also more likely to choose more lethal means of suicide.

For example, these individuals were more likely to die by gunshot or hanging, rather than poisoning or cuts. This was true regardless of gender. In other words, females who thought they were a burden were more likely to use a more lethal method of suicide.

Suicide myths

“People who talk about suicide will not kill themselves.” Up to 90% of suicides give some kind of prior warning.

Conversely, some people believe that talking about suicide to someone contemplating it will make it more likely that they will make an attempt. This is also not supported by studies.

A model of suicide

These findings lend themselves to a heuristic model for suicide. This model proposes that, in order to attempt suicide, an underlying condition, such as a mood disorder, anxiety disorder, perfectionism, substance abuse, and/or impulsivity is likely to be present.

The suicide act itself will usually be preceded by a stressful event that may be a result of the underlying condition. Psychological autopsy studies suggest that the stress commonly leads to extreme anxiety or distress.

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Inhibitory and facilitating factors come into play after the precipitating event and the balance between them will determine whether the outcome is an attempt at suicide or not. Inhibiting factors that make suicide less likely include living in a culture in which suicide is strongly taboo, having available support or the presence of others, and having a slowed-down mental state. Conversely, the presence of other factors may facilitate suicide. These include living in a culture in which taboos about suicide are weak, having ready access to weapons or other methods of suicide, learning of a recent example of suicide by hearsay or in the media, being in an agitated or excited state, and being alone.

Treatment

First it is important to assess where the person is in terms of:

Previous attempts Recent events Ideation Creating a plan The plan includes a means Access to the means They have made preparations not to be discovered.

Some treatment options that have evidence of effectiveness: No-suicide contract Hospitalisation

o Complete or partial Problem Solving Therapy works on the premise that suicide and parasuicide

involve a problem-solving failure of some kind Manual-assisted Cognitive-Behaviour Therapy (MACT), which involves the

patient receiving manuals as well as sessions of CBT

Suicide Prevention

Reducing the access to lethal means can reduce suicide deaths. Although some people may choose alternate means, there is evidence that some people have a preferred method and if that is not available, they do not attempt suicide. Or the alternative may be less lethal, thus increasing the likelihood of interception.

In some countries, paracetamol is only sold in packets of 16 tablets or less, without a prescription. First time parasuicides often do not know the deadly dose (20 tablets with a large quantity of alcohol can kill) and so may take a non-lethal dose.

The Early Psychosis Prevention and Intervention Centre in Melbourne, reports success in reducing the incidence of suicide among young people diagnosed with a psychotic disorder. The principles of the centre can be applied to preventing all types of suicide:

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To enhance the early detection of psychosis To improve mechanisms for access to psychiatric services To develop 'user-friendly' non-stigmatising mental health services for young

people To develop adequate support for the carers of individuals with psychosis To develop more effective treatments for those with, or at risk of, developing

early psychosis To develop suicide prevention structures within health services

The non-stigmatising element is particularly important for young men. Many men are taught from an early age not to show weakness, to be independent and not to seek help for problems – this is not a good combination in a young man with suicidal thoughts.

O'Connor and Sheehy (2000) propose five general education and prevention strategies aimed at high-risk individuals, healthcare professionals and the general public:

1. Promoting the importance of communication. Men in particular should be encouraged to communicate their worries and anxieties.2. The coping strategies of suicidal individuals must be dysfunctional in some way if they perceive suicide as the only option. Research into the different coping strategies of suicidal and non-suicidal individuals should identify important differences, which can then become part of educational packages. More effective strategies, such as seeking social support and religious coping should be considered.3. Difficulties in coping with stressful situations are not a sign of personal weakness. It is necessary to change the general perceptions of stressors and people's perceptions of their own situations. Communication with significant others and healthcare professionals is beneficial. Our perceptions of stressful life events are crucial to the prediction of suicide.4. The prevalence of depression needs to be highlighted and mood disorders destigmatised. Knowledge of the suicidal risk factors needs to be spread more widely.5. Awareness of the existing services for counselling and helping people cope with mood disorders also needs spreading. Counselling services should be used more often in conjunction with GP consultations. Setting up specialist telephone help lines and encouraging people to use them would also be useful.

Other strategies that have proved useful elsewhere include company training programmes aimed at stress management and communication skills. USA-style Suicide Prevention Centres may be useful in providing support for people, in addition to telephone help lines. However, this is one of the more expensive options.

Care needs to be taken in how the media portrays suicide. Portrayals glamorising the suicide of Kurt Cobain, singer with rock band Nirvana, may have led to the increase in suicides by young people shortly after, although that did not happen in Seattle, Cobain’s home town, as the press there followed the guidelines on responsible coverage of suicide. Portrayals of suicides in two major British television series, Eastenders and Casualty, were also followed by increases in suicide. In the case of the latter, by 17% in the week following and by 9% in the second week. Also, the method portrayed was paracetamol and the increase in paracetamol poisoning was greater than other forms of self-poisoning.

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Educating GPs, counsellors and psychologists to better recognise patients at risk of suicide would help, as would alerting them to the known risk factors.

One of the more promising approaches for men, and young men in particular, is to access support via the Internet. They could access the already existing support groups, if they knew about them.

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References

Azam, R., Phillips, D., & Kumar, S. Suicide by Paraquat Ingestion in Fiji. Unpublished paper. Fiji School of Medicine.

Baume, P. J. M., Cantor, C. H., & McTaggart, P. G. (1998). Suicide in Queensland: A comprehensive study. Brisbane: Australian Institute for Suicide Research and Prevention.

Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42, 861-865.

Booth, H. (1997). Casualties of development? Child and youth suicide in the pacific. Development Bulletin on Child-Focussed Development.

Brown, S. L., & Vinokur, A. D. (2003). The interplay among risk factors for suicidal ideation and suicide: The role of depression, poor health, and loved ones' messages of support and criticism. American Journal of Community Psychology, 32, 131-141.

Furey, M. L., & Drevets, W. C. (2006). Antidepressant efficacy of the antimuscarinic drug scopolamine: a randomized, placebo-controlled clinical trial. Archives of General Psychiatry, 63, 1121-1129.

Harrison, J., Moller, J., & Bordeaux, S. (1997). Youth suicide and self-injury Australia (No. 15 (supplement)).

Maris, R. F. W. (1991). Introduction to a special issue: Assessment and prediction of suicide. Suicide and Life-Threatening Behavior, 21, 1-17.

O'Connor, R., & Sheehy, N. (2000). Understanding Suicidal Behaviour. Leicester: British Psychological Society.

Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. The New England Journal of Medicine, 358(3), 252-260.

Watanabe, N., Hasegawa, K., & Yoshinaga, Y. (1995). Suicide in later life in Japan: Urban and rural differences. International Psychogeriatrics, 7, 253-261.

Zimmerman, M., Ruggero, C. J., Chelminski, I., & Young, D. (2009). Psychiatric Diagnoses in Patients Previously Overdiagnosed With Bipolar Disorder. Journal of Clinical Psychiatry.

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