1. Chapter 6 Mood Disorders and Suicide

2. An Overview of Depression and Mania Mood disorders – Gross deviations in mood – Major depressive episodes – Manic and hypomanic episodes

3. An Overview of Depression and Mania Types of DSM-IV-TR depressive disorders – Major depressive disorder – Dysthymic disorder – Double depression

4. An Overview of Depression and Mania Types of DSM-IV-TR bipolar disorders – Bipolar I disorder – Bipolar II disorder – Cyclothymic disorder

5. Major Depression: An Overview Major depressive episode: Overview and defining features – Extremely depressed mood lasting at least two weeks – Cognitive symptoms – feelings of worthlessness, indecisiveness – Disturbed physical functioning – Anhedonia – loss of pleasure/interest in usual activities

6. The Structure of Mood Disorders Mania Hypomanic episode – Dysphoric manic episode or mixed manic episode

7. The Structure of Mood Disorders Features of a manic episode – Elevated, expansive mood for at least one week – Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors – Impairment in normal functioning

8. Major Depression: An Overview Major depressive disorder – Single episode – highly unusual – Recurrent episodes – more common From grief to depression – Pathological or impacted grief reaction

9. Dysthymia: An Overview Overview and defining features – Symptoms are milder than major depression – Persists for at least two years – No more than two months symptom free – Symptoms can persist unchanged over long periods (≥ 20 years) Facts and statistics – Late onset – typically in the early 20s

10. Double Depression: An Overview Overview and defining features – Major depressive episodes and dysthymic disorder – Dysthymic disorder often develops first Facts and statistics – Associated with severe psychopathology – Associated with a problematic future course

11. Bipolar I Disorder: An Overview Overview and defining features – Alternations between full manic episodes and depressive episodes Facts and statistics – Average age of onset is 15-18 years – Can begin in childhood – Tends to be chronic – Suicide is a common consequence

12. Bipolar II Disorder: An Overview Overview and defining features – Alternations between major depressive and hypomanic episodes Facts and statistics – Average age of onset is 19-22 years – Can begin in childhood – 10% to 25% of cases progress to full bipolar I disorder – Tends to be chronic

13. Cyclothymic Disorder: An Overview Overview and defining features – Chronic version of bipolar disorder – Manic and major depressive episodes are less severe – Manic or depressive mood states persist for long periods – Must last for at least two years (one year for children and adolescents)

14. Cyclothymic Disorder: An Overview Facts and statistics – Average age of onset is 12 to 14 years – Most are female – Cyclothymia tends to be chronic and lifelong – One third to one half develop full-blown bipolar

15. Prevalence of Mood Disorders Worldwide lifetime prevalence – 16% for major depression 6% have experienced major depression in last year Sex differences – Females are twice as likely to have major depression – Bipolar disorders equally affect males and females

16. Prevalence of Mood Disorders Occurs less often in prepubertal children Rapid rise in adolescents Adults over 65 have about 50% less than adults Bipolar same in childhood, adolescence and adults Prevalence of depression seems to be similar across subcultures

17. Life Span Developmental Influences on Mood Disorders Three-month-olds can show depression Children below nine do not show class mania or bipolar symptoms Mood disorder are often misdiagnosed as ADHD Children are being diagnosed with bipolar at increasingly high rates

18. Life Span Developmental Influences on Mood Disorders Depression in elderly between 14% and 42% – Corroccurance with anxiety disorders – Less gender imbalance after 65 years of age Cultural differences exist – Hopi say they are “Heartbroken” – Native American population have four times the rate as the general population

19. Mood Disorders: Familial and Genetic Influences Family studies – Rate is high in relatives of probands – Relatives of bipolar probands tend to have unipolar depression

20. Mood Disorders: Familial and Genetic Influences Twin studies – Concordance rates are high in identical twins two to three times more likely to present with mood disorders – Severe mood disorders have a strong genetic contribution – Heritability rates are higher for females compared to males, 40% women and 20% men

21. Mood Disorders: Familial and Genetic Influences Twin studies – Vulnerability for unipolar or bipolar disorder Appears to be inherited separately – Some genetic factors are common for mood and anxiety disorders

23. Mood Disorders: Neurobiological Influences Neurotransmitter systems – Serotonin and its relation to other neurotransmitters – Mood disorders are related to low levels of serotonin – Permissive hypothesis

24. Mood Disorders: Neurobiological Influences The endocrine system – Elevated cortisol – Hippocampus and neurogenesis Sleep disturbance – Hallmark of most mood disorders – REM and depression – Relation between depression and sleep

25. Mood Disorders: Psychological Dimensions (Stress) Stressful life events – Stress is strongly related to mood disorders Poorer response to treatment Longer time before remission – The relation between context of life events and mood – Reciprocal-gene environment model – The relationship between stress and bipolar is also string

27. Mood Disorders: Psychological Dimensions (Learned Helplessness) The learned helplessness theory of depression – Lack of perceived control over life events

28. Mood Disorders: Psychological Dimensions (Learned Helplessness) Learned helplessness and a depressive attributional style – Internal attributions Negative outcomes are one’s own fault – Stable attributions Believing future negative outcomes will be one’s fault – Global attribution Believing negative events will disrupt many life activities – All three domains contribute to a sense of hopelessness

29. Mood Disorders: Psychological Dimensions (Cognitive Theory) Negative coping styles – Depressed persons engage in cognitive errors – Tendency to interpret life events negatively Types of cognitive errors – Arbitrary inference – overemphasize the negative – Overgeneralization – negatives apply to all situations

30. Mood Disorders: Psychological Dimensions (Cognitive Theory) Cognitive errors and the depressive cognitive triad – Think negatively about oneself – Think negatively about the world – Think negatively about the future Seligman and Becks theories

33. Mood Disorders: Social and Cultural Dimensions Marital relations – Marital dissatisfaction is strongly related to depression – This relation is particularly strong in males

34. Mood Disorders: Social and Cultural Dimensions Mood disorders in women – Females over males – Except bipolar disorders – Gender imbalance likely due to socialization

36. Mood Disorders: Social and Cultural Dimensions Mood disorders in women – 70% of major depression and dysthymia are women – Perception of uncontrollability – Parenting styles – Stereotypical gender roles – Social networks – Women ruminate more than men

37. Mood Disorders: Social and Cultural Dimensions Social support – Extent of social support is related to depression – Lack of social support predicts late onset depression – Substantial social support predicts recovery from depression

38. An Integrative Theory Shared biological vulnerability – Overactive neurobiological response to stress Inadequate coping and depressive cognitive style – Diathesis-stress model Biological, psychological and social factors all influence the development of mood disorders Exposure to stress

40. Treatment of Mood Disorders: Selective Serotonergic Reuptake Inhibitors (SSRIs) Specifically block reuptake of serotonin – Fluoxetine (Prozac) is the most popular SSRI SSRIs pose some risk of suicide particularly in teenagers Negative side effects are common

41. Treatment of Mood Disorders: Tricyclic Antidepressants Widely used (e.g., Tofranil, Elavil) Block reuptake – Norepinephrine and other neurotransmitters Therapeutic effects – Can take two to eight weeks Negative side effects are common May be lethal in excessive doses

42. Treatment of Mood Disorders: Mixed Reuptake Inhibitors Venlafaxine (Effexor)- blocks norepinephrine as well as serotonin Nefazodone (Serzone) – improves sleep efficiency Both have fewer side effects than SSRIs

43. Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors Monoamine oxidase (MAO) – Block monoamine oxidase – This enzyme breaks down serotonin/norepinephrine – Slightly more effective than tricyclics

44. Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors Must avoid foods containing tyramine – Examples include beer, red wine, cheese – Many patients do not like the dietary restrictions

45. Treatment of Mood Disorders: Lithium Lithium is a common salt – Primary drug of choice for bipolar disorders – Can be toxic Side effects may be severe – Dosage must be carefully monitored – Lithium is a mood-stabilizing drug Why lithium works remains unclear

46. Treatment of Mood Disorders: Electroconvulsive Therapy (ECT) ECT is effective for cases of severe depression The nature of ECT – Involves applying brief electrical current to the brain – Results in temporary seizures – Usually six to 10 outpatient treatments are required

47. Treatment of Mood Disorders: ECT – Side effects are few and include short-term memory loss – Uncertain why ECT works – Relapse is common Transcranial Magnetic Stimulation (TMS) – Uses magnets to generate a precise localized electromagnetic pulse

48. Psychosocial Treatments Cognitive-behavioral therapy – Addresses cognitive errors in thinking – Also includes behavioral components Interpersonal psychotherapy – Focuses on problematic interpersonal relationships Prevention Combined treatments for depression Prevention relapse of depression Psychosocial treatments for bipolar

50. Psychosocial Treatments Outcomes with psychological treatments – Comparable to medications – Research does not suggest advantage for combined treatment

51. The Nature of Suicide: Facts and Statistics 11th leading cause of death in the United States- maybe two to three times higher Overwhelmingly a white and Native American phenomenon China and suicide rates Suicide rates are increasing, particularly in the young

52. The Nature of Suicide: Facts and Statistics Gender differences – Males are more successful at committing suicide than females – Females attempt suicide more often than males

53. The Nature of Suicide: Risk Factors Risk factors – Suicide in the family – Low serotonin levels – Preexisting psychological disorder – Alcohol use and abuse – Stressful life event – Past suicidal behavior – Suicide contagion Treatment

54. Summary of Mood Disorders All mood disorders share: – Gross deviations in mood – Common biological and psychological vulnerability Occur in children, adults, and the elderly Onset, maintenance, and treatment are affected by – Stress – Social support

55. Summary Suicide is an increasing problem – Not unique to mood disorders Medications and psychotherapy produce comparable results High rates of relapse

56. DSM-5 Proposed Changes http://www.dsm5.org/ProposedRevisions/Pag es/MoodDisorders.aspx http://www.dsm5.org/ProposedRevisions/Pag es/MoodDisorders.aspx