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 Cognitive symptoms such as worthlessness and indecisiveness Dysfunction is physical and includes sleep, appetite, energy levels Anhedonia loss of pleasure or interest in things Technology Tip: Check out the site of the National Foundation for Depressive Illness, Inc., for more information on depression. http://www.depression.org/ Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: A Self-Rating Depression Scale.

Exaggerated elation, joy, euphoria 1 week, or less Cognitive symptoms 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 Cognitive symptoms flight of ideas, grandiosity Dysfunction is physical and includes decreased sleep, hyperactive, rapid speech 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

Structure of Mood Disorders Unipolar disorders Depression or mania alone Typically depression Bipolar disorders Depression and mania Mixed episodes Technology Tip: Check out The National Institute of Mental Health site devoted to depression and bipolar disorder. http://www.nimh.nih.gov/publicat/depression.cfm

Structure of Mood Disorders Diagnostic considerations Accompanying symptoms Overlap between disorders Severity Course Recurrent Alternating Seasonal Symptom overlap includes weight changes, irritability, cognitive distortions, sleep changes

Depressive Disorders: An Overview Major Depressive Disorder No mania/hypomania Single episode Rare Recurrent 4 episodes (lifetime) Duration – 4 to 5 months Single episode - as many as 85% of single-episode cases later have a second episode Recurrent – two or more episodes separated by two months or more during which the individual was not depressed Teaching Tip: The movies Ordinary People and Leaving Las Vegas provide depictions of depression. Technology Tip: The Major Depressive Disorder Internet Mental Health provides this informative web page; information on other disorders is provided as well. http://www.mentalhealth.com/p20-grp.html

Major Depressive Disorder Onset Low until early teens Mean age = 30 Figure 7.1 – Cross cultural data on the onset of major depressive disorder Technology Tip: Dr. Ivan’s Depression Central offers links to several sites on mood disorders, including sites for books, videos, research, diagnosis, and treatment. http://www.psycom.net/depression.central.html

Depressive Disorders: An Overview Dysthymic Disorder Milder symptoms 2+ years Chronic Persistent Chronic - can persist unchanged 20-30 years Persistent- cannot be symptom free for more than 2 months at a time Technology Tip: Dysthymia Internet Mental Health provides this informative web page; information on other disorders are provided as well. http://www.mentalhealth.com/p20-grp.html

Stronger familial component Median duration = 5 years Dysthymic Disorder Onset = early 20’s Early onset = before 21 Greater chronicity Poor prognosis Stronger familial component Median duration = 5 years Depends on comorbidity Chronic - can persist unchanged 20-30 years Persistent- cannot be symptom free for more than 2 months at a time

Dysthymic Disorder Figure 7.2 HDRS scores of dysthymic disorder patients

Depressive Disorders: An Overview Double Depression Major depressive episodes and dysthymic disorder Dysthymia first Severe psychopathology Poor course High recurrence rates Recurrence is high if dysthymia is untreated Teaching Tip: Have students participate in the following Instructor Resource Manual Video Activity: Abnormal Psychology, Inside/Out, Vol. 1. After reviewing the nature of depressive disorders, present the video segment depicting Barbara, but do not let on about her diagnosis. Ask students to see if they can arrive at a diagnosis for Barbara. The correct answer is Unipolar Depression, without Psychosis.

Depression frequently follows loss 62% after death Grief and Depression Depression frequently follows loss 62% after death Pathological or Complicated Grief Severity of symptoms Dysfunction Persistence of symptoms Technology Tip: The following articles offer interesting information on grief and depression: http://news-service.stanford.edu/pr/94/940829Arc4145.html http://pn.psychiatryonline.org/cgi/content/full/42/15/28-a Technology Tip: Interesting information and links about bereavement and grief: http://www.psycom.net/depression.central.grief.html

Bipolar I Disorder: An Overview Alternating major depressive and manic episodes Single manic episode Recurrent Symptom free for 2 months Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Bipolar Disorder Screening Technology Tip: Bipolar Disorder Internet Mental Health provides this informative web page; information on other disorders are provided as well. http://www.mentalhealth.com/p20-grp.html Teaching Tip: Have students read the complete book or excerpts from Kay Jamison’s book, An Unquiet Mind, which offers excellent insight into bipolar disorder.

Bipolar I Disorder: An Overview Statistics Onset = age 18 Childhood Chronic Suicide Suicide attempts 17% for BP I, 24% for BPII, 12% unipolar depression, completed suicide is 4x higher than depression Technology Tip: Visit the following NIMH site for more information on bipolar disorders and suicide: http://www.nimh.nih.gov/publicat/bipolar.cfm

Alternating major depressive and hypomanic episodes Bipolar II Disorder Alternating major depressive and hypomanic episodes Statistics Onset = age 19 to 22 Childhood Chronic 10 to 13% of cases progress to full Bipolar I disorder Technology Tip: The University of Maryland Medical Center site offers more information on the distinction between bipolar I and II: http://www.umm.edu/patiented/articles/what_bipolar_disorder_000066_1.htm

Alternating manic and depressive episodes Less severe Persists longer Cyclothymic Disorder Alternating manic and depressive episodes Less severe Persists longer Chronic symptoms Adults = 2+ years children and adolescents= 1+ year Technology Tip: Cyclothymia Internet Mental Health provides this informative web page; information on other disorders are provided as well. http://www.mentalhealth.com/dis/p20-md03.html

Cyclothymic Disorder Statistics Onset = age 12 or 14 Chronic Lifelong Female>Male Risks for Bipolar I/II High risk for developing Bipolar I or II disorder

Additional Defining Criteria Symptom Specifiers Atypical Melancholic Chronic Catatonic Psychotic Mood congruent/ incongruent Postpartum Atypical – Oversleep, overeat, weight gain, anxiety Melancholic – Severe depressive and somatic symptoms Chronic – Major depression only, lasting 2 years Catatonic – Absence of movement, very serious Psychotic – Mood congruent hallucinations/delusions Mood incongruent features possible, but rare Postpartum – Manic or depressive episodes after childbirth

Additional Defining Criteria Figure 7.3 Mood disorders and specifiers for the most recent episode of the disorder

Additional Defining Criteria Course Specifiers Longitudinal course Rapid cycling pattern Seasonal pattern Depression vs. mania Melatonin Phototherapy CBT Technology Tip: Visit the Mayo Clinic site for more information on SAD: http://www.mayoclinic.com/health/seasonal-affective-disorder/DS00195 Longitudinal course specifiers are used to address whether a person has had a past episode of depression or mania and whether the person recovered fully from past episodes. For example, one should determine whether dysthymia preceded a major depressive episode or whether cyclothymic disorder preceded bipolar disorder. Both scenarios tend to decrease chances of recovery and increase length of treatment. Rapid cycling pattern applies only to bipolar I and II disorders. Rapid cycling pattern is used when a person has at least 4 manic or depressive episodes within a period of 1 year. Rapid cycling is a more severe form of bipolar disorder that does not respond well to treatment, and appears to be associated with higher rates of suicide. Alternative drug treatments (e.g., anticonvulsants, mood stabilizers) are typically utilized with individuals meeting criteria for this specifier. Seasonal pattern applies to bipolar disorders and recurrent major depression and is used to indicate whether episodes occur during certain seasons, usually wintertime. Those with winter depressions display excessive sleep and weight gain. Seasonal affective disorder may be related to circadian and seasonal changes in the increased production of melatonin (i.e., a hormone secreted by the pineal gland). Phototherapy is a recommended effective treatment for this condition.

Prevalence of Mood Disorders Table 7.3 Prevalence of mood disorders

Prevalence of Mood Disorders Children and Adolescents Similar to adults Symptom presentations Prevalence Early childhood Adolescence Misdiagnosis ADHD Conduct disorder Technology Tip: For more information, visit the NIMH site: www.nimh.nih.gov/healthinformation/depchildmenu.cfm Children fundamentally similar to adults; no childhood mood disorders in the DSM-IV-TR. Children less than 9 years of age show more irritability and emotional swings rather than classic manic states, and are often mistaken as hyperactive. 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. Bipolar disorder is rare in childhood, but rises substantially in adolescence and so does suicide.

Prevalence of Mood Disorders Elderly Prevalence may depend on setting Symptom profile Female : Male = 1:1 Diagnostic difficulty Comorbidities Technology Tip: For more information, visit the following sites: www.nami.org/helpline/elddepres.htm ; http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm Elderly - 18% to 20% of nursing home residents, likely to be chronic. Symptoms- sleep problems, hypochondriasis, and agitation. Diagnostic difficulty- medical illnesses and symptoms of dementia; menopause for women Prevalence - MDD is the same or slightly lower as in the general population. Comorbidities- GAD and panic disorder (33%), alcohol (33%), Gender - imbalance in depression disappears after age 65.

Prevalence of Mood Disorders Across Cultures Similar prevalence among US subcultures Exceptions Physical or somatic symptoms Comparability Exceptions – Native American village depression was 1.5 to 4x higher than general population; SES and stress Symptoms- weakness, tiredness Comparability – constructs, statements, wording

Prevalence of Mood Disorders Among the creative Higher prevalence Melancholia Mania Gender differences Jamison study- 20% or more prevalence rate of bipolar for recent American poets Gender – female poets, more than other artists and politicians, perhaps due to independent and sometimes rebellious qualities in the context of gender roles.

Overlap of Anxiety and Depression 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 Technology Tip: The following Reuters article discusses the overlap between depression and anxiety: http://www.reuters.com/article/healthNews/idUSKRA47465020070614 Technology Tip: The following Psychology Today article discusses the overlap between depression and anxiety: http://psychologytoday.com/rss/pto-20070709-000005.html

Causes of Mood Disorders : Biological Familial and Genetic Influences Family Studies Adoption Studies Twin Studies Bipolar Unipolar Higher concordance with higher severity Higher heritability for females Family Studies- rate is 2-3x higher in relatives of probands Adoption Studies Twin Studies – identical twins are 2-3x more likely than fraternal Bipolar: identical 66.7%, fraternal 18.9%; Unipolar: identical 45.6%, fraternal 20.2% Females 40% vs 20% for males

Causes of Mood Disorders : Biological Figure 7.4 Co-occurrences of types of mood disorders in twins

Depression and Anxiety: The Same Genes? Shared genetic vulnerability High familial heritability Same genetic factors General predisposition Except mania? Technology Tip: Visit the site for the Johns Hopkins Department of Psychiatry and Behavioral Sciences Genetics of Mood Disorders research website: http://www.hopkinsmedicine.org/psychiatry/moods/genetics

Causes of Mood Disorders : Biological Neurotransmitter Systems Serotonin - depression The “permissive” hypothesis Dopamine Norepinephrine Dopamine - mania Technology Tip: Visit the following sites for more information on the neurobiology of depression and the “permissive hypothesis”: http://thebrain.mcgill.ca/flash/a/a_08/a_08_m/a_08_m_dep/a_08_m_dep.html http://www.nevdgp.org.au/info/topics/depression_theory.htm

Causes of Mood Disorders : Biological Endocrine System “Stress hypothesis” Overactive HPA axis Neurohormones Elevated cortisol Suppressed hippocampal neurogenesis Dexamethasone suppression test (DST) Neurohormones – unclear, but likely relationship to antecedent neurotransmitters DST- Dexamethasone depresses cortisol secretion; 50% with mood disorders show less suppression Suppressed hippocampal neurogenesis – via long term production of stress hormones

Causes of Mood Disorders : Biological Sleep and Circadian Rhythms REM sleep Reduced latency Increased intensity Decreased slow wave sleep Sleep deprivation effects Sleep deprivation during the second half of the night causes temporary mood improvements Technology Tip: Check out the following article for more information on using sleep deprivation to treat depression: http://www.webmd.com/news/19991116/benefits-sleep-deprivation-depression

Causes of Mood Disorders : Biological Brain Wave Activity Indicator of vulnerability? Greater right side anterior activation Less alpha wave activity This pattern is seen in individuals who are no longer depressed and in adolescent offspring of depressed mothers- may be a indicator of a biological vulnerability

Causes of Mood Disorders : Psychological Stressful life events Context Meaning Timing Effects of stress Poorer treatment response Delayed remission Trigger for episode or relapse Bipolar- episodes triggered by lack of sleep or jetlag.

Causes of Mood Disorders : Stress Reciprocal-gene environment model Stress triggers depression Depressed individuals create or seek out stressful situations Interaction with vulnerability Genetic Psychological Reciprocal-gene environment model – genetic endowment may increase the probability of experiencing a stressful life event

Causes of Mood Disorders : Psychological Learned Helplessness (Seligman) Lack of perceived control Depressive Attributional Style Internal Stable Global Also characterizes anxiety Internal - Negative outcomes are one’s own fault Stable- Believing future negative outcomes will be one’s fault Global- Believing negative events disrupt many life activities

Causes of Mood Disorders : Psychological Sense of hopelessness Lack of perceived control Will not regain control Pessimism Before or after? Those with anxiety do not give up and become hopeless about regaining control

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 Arbitrary inference – Overemphasize the negative Overgeneralization – Negatives apply to all situations Technology Tip: Visit Dr. Beck’s homepage for more information and links: http://mail.med.upenn.edu/~abeck/

Causes of Mood Disorders : Psychological Beck’s Depressive Cognitive Triad Figure 7.6 Beck’s cognitive triad for depression.

Causes of Mood Disorders : Psychological Cognitive Theory of Depression (Beck) Negative schemas Automatic thoughts Treatment implications Correcting the errors Technology Tip: The Beck Institute website offers more information on research and treatment related to CBT: http://www.beckinstitute.org

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 Conflict and support- both may be high, low, or absent, or any combination Gender and cause – depression causes men to withdraw or otherwise disrupt the relationship, for women relationship problems cause depression

Mood Disorders: Social and Cultural Dimensions Mood Disorders in Women Prevalence: Females > males True for all mood disorders Except bipolar Figure 7.7 Lifetime international rate per 100 people for major depression.

Mood Disorders: Social and Cultural Dimensions Mood Disorders in Women Gender roles Perceptions of uncontrollability Socialization Access to resources Gender differences in: Feelings of mastery, control, and being valued Technology Tip: Facts about Women and Depression An NIMH web page, containing many facts regarding women and mental health. http://www.nimh.nih.gov/HealthInformation/depwomen.cfm

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 Shared Biological Vulnerability - overactive neurobiological response to stress, similar to anxiety Psychological vulnerability – pessimism, sense of uncontrollability, helplessness and hopelessness Exposure to Stress - activates hormones, neurotransmitter systems, certain genes, affects circadian rhythms Social and interpersonal relationships- act as moderators

Integrative Theory of Mood Disorders Figure 7.8 An integrative model 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 Side effects - 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. Efficacy -tricyclics alleviate depression in 50% of cases to as high as 65% to 70% of cases. Technology Tip: Info on pharmacological treatments for depression can be found at: http://www.ahcpr.gov/clinic/epcsums/deprsumm.htm

Treatment : Antidepressant Medications Monoamine Oxidase (MAO) Inhibitors Block MAO Higher efficacy Fewer side effects Interactions Foods Medicines Selective MAO-Is Monoamine Oxidase (MAO) - Enzyme that breaks down serotonin/norepinephrine Efficacy- slightly more effective than tricyclics and have fewer side effects. However, ingestion of 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 (not yet widely available) are more selective, short acting, and do not interact negatively with tyramine. MAO inhibitors are usually prescribed only when tricyclics prove to be ineffective.

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 Side effects - physical agitation, sexual dysfunction or low desire, insomnia, and gastrointestinal upset.

Treatment : Antidepressant Medications Other medications Venlafaxine Similar to tricyclics Nefazodone Similar to SSRIs St. John’s Wort Questionable efficacy Technology Tip: For more information on St. John’s Wort and depression, visit the following sites: nccam.nih.gov/health/stjohnswort www.hypericum.com www.umm.edu/altmed/articles/stjohns-wort-000276.htm

Treatment : Antidepressant Medications Other issues Efficacy in special populations Children Elderly Preventing relapse Maintaining benefits Children- cardiac problems Elderly- increased side effect profiles Technology Tip: The following article from the APA Monitor discusses treatment efficacy in the elderly http://www.apa.org/monitor/mar99/depress.html

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 Mechanism- may work on dopamine, norepinephrine, and/or the endocrine system; electrolytes Technology Tip: Visit the following site for more information on the treatment of bipolar disorders: http://www.bipolar-disorders.com/

Treatment of Mood Disorders: Antimanics Other antimania drugs Carbamazepine Valproate Most frequently prescribed High efficacy Except suicide! Fewer side effects

Treatment of Mood Disorders: ECT Electroconvulsive Therapy Brief electrical current Temporary seizures 6 to 10 treatments High efficacy Severe depression Few side effects Relapse is common Side effects - Short-Term Memory Loss, confusion, both are transient Efficacy -50% not responding to meds will get better Technology Tip: The site www.ect.org has some interesting (and controversial) information from a former patient who underwent the procedure.

Treatment of Mood Disorders: TMS Transcranial magnetic stimulation Localized electromagnetic pulse Fewer side effects Efficacy is likely good More studies needed Side effects - headaches Efficacy -50% not responding to meds will get better Technology Tip: The following sites offer links and more information on TMS: www.mayoclinic.com/health/transcranial-magnetic-stimulation/MH00115 www.musc.edu/tmsmirror/intro/layintro.html groups.csail.mit.edu/vision/medical-vision/surgery/tms.html www.nami.org/Content/ContentGroups/Helpline1/Transcranial_Magnetic_Stimulation_(rTMS).htm

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 Technology Tip: The Beck Institute website offers more information on research and treatment related to CBT: http://www.beckinstitute.org

Psychological Treatment of Mood Disorders Interpersonal Psychotherapy Address interpersonal issues in relationships Role disputes Loss New relationships Social skill deficits Address interpersonal role disputes, adjustments to losing a relationship, acquisition of new relationships, and social skills deficits. Technology Tip: The International Society for Interpersonal Psychotherapy site provides information about IPT and its clinical and research applications: www.interpersonalpsychotherapy.org/ Technology Tip: Also see the University of Michigan site on IPT: www.med.umich.edu/depression/ipt.htm

Psychological Treatment of Mood Disorders CBT and IPT Outcomes Comparable to medications More effective than: Placebo Brief psychodynamic treatment Technology Tip: The following article from the APA Monitor discusses treatment efficacy compared to medications: http://www.apa.org/monitor/sep99/nl11.html

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 Universal programs – applied to everyone Selected interventions – those at increased risk (divorce, family alcoholism) Indicated interventions –those showing early signs of depression Figure 7.9 Hollon et al. (2006) Annual Review of Psychology

Psychological Treatment of Bipolar Disorders Management of interpersonal problems Increase medication compliance Interpersonal and Social Rhythm Therapy Family-focused treatment Interpersonal and Social Rhythm Therapy -Regulates circadian rhythms, Sleep, eating cycles, Decreased relapse Technology Tip: The following article offers more information on ISRT: www.medicalnewstoday.com/articles/30240.php

Suicide: Statistics Population specific Caucasians Native Americans Increasing rates Adolescents Elderly Gender differences Indices Attempts Ideations Males are more likely to commit suicide Females are more likely to attempt suicide Technology Tip: Visit the NIH Suicide Prevention site for more information on suicide statistics and prevention: http://www.nimh.nih.gov/suicideprevention/index.cfm Teaching Tip: The movies The Hours, Dead Poet’s Society, and The Virgin Suicides provide illustrations of suicide and the effects on others

Suicide: Past Conceptions Types of suicide (Durkheim) Altruistic Egoistic Anomic Fatalistic Formalized or altruistic suicide is socially or familially sanctioned (e.g., to avoid dishonor to self or family). Egoistic suicide, which may be common in the elderly, is suicide caused by disintegration of social support. Anomic suicides occur following some major disruption in one's life (e.g., sudden loss of a high prestige job).. Fatalistic suicides related to a loss of control over one's destiny (e.g., mass suicide of Heaven’s Gate cult).

Past suicidal behavior Shameful/humiliating stressor Suicide: Risk Factors Family history Low serotonin levels Preexisting disorder Alcohol Past suicidal behavior Shameful/humiliating stressor Suicide publicity and media coverage Technology Tip: The Suicide Information and Education Center site has more information on risk and resources http://www.siec.ca/siec.htm Technology Tip: For more information, visit the American Association of Suicidology site: http://www.suicidology.org/ Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Suicide Questionnaire

Suicide: Risk Factors Figure 7.14 Threshold model for suicidal behavior

Importance of assessment Previous attempts Recent events Ideation Plan Suicide: Treatment Importance of assessment Previous attempts Recent events Ideation Plan Means Access Technology Tip: For more information, visit : http://www.psycom.net/depression.central. suicide.html Technology Tip: The Suicide Awareness/Voices of Education site includes links and other information on suicide: http://www.save.org/

Problem solving therapy CBT Suicide: Treatment No-suicide contract Hospitalization Complete or partial Problem solving therapy CBT Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Suicide Prevention Discussion Tip: Lead a discussion on the strengths and weakness of a “no suicide” contract. How would it be different if it were verbal, written, witnessed, or worded by the individual versus the therapist? What are the legal ramifications for the therapist?

Future Directions Interaction between biology and psychology Biological challenge studies Induced depression Serotonin and pessimism