CHAPTER Five

1. CHAPTER Five Mood Disorders and Suicide Symptoms Diagnosis Course and Outcome Frequency Causes Treatment Suicide

2. OVERVIEW • Major depression is the leading cause of disability worldwide. • Depression accounts for 10% of all disability. • Affect: pattern of observable behaviors • Facial expression, pitch of voice, body movements • Mood: a pervasive and sustained emotional response that can color perception.

3. OVERVIEW Mood disorders are defined in terms of episodes- discrete periods of time in which the person’s behavior is dominated by either a depressed or manic mood. DSM-IV-TR defines 3 mood episodes. • Major depressive episode • Manic episode • Hypomanic episode

4. Overview The 3 mood episodes form the basis of the 5 mood disorders: Unipolar disorders – individual experiences only abnormally low moods (major depression, dysthymia). Bipolar disorders – individual experiences both abnormally low and high moods (Bipolar I, Bipolar II, cyclothymia). Depression Mania

5. Mood Episodes

6. Mood Episodes

7. Mood Disorders • Hypomanic episode - a less extreme version of a manic episode that is not severe enough to significantly interfere with functioning.

8. The DSM-IV-TR Mood Disorders 1) Major depressive disorder One or more major depressive episode(s) No history of manic or hypomanic episodes Subtypes Catatonic Features Psychotic Features Melancholic Features Postpartum Onset Seasonal Pattern

9. The DSM-IV-TR Mood Disorders 2) Dysthymic Disorder: Two years or more of consistently depressed mood and other symptoms that are not severe enoughto meet criteria for a major depressive episode.

10. The DSM-IV-TR Mood Disorders 3) Bipolar I disorder Combination of major depressive episodes and manic episodes. 4) Bipolar II disorder Combination of major depressive episodes & hypomanic episodes.

11. The DSM-IV-TR Mood Disorders 5) Cyclothymic disorder Two years or moreof consistent mood swings between hypomanic highs and dysthymiclows.

12. COURSE AND OUTCOME • Unipolar Disorders • Average age of onset = 32 but impacts ALL age groups. • Length of episodes vary widely • Relapse: a return of active symptoms • Approximately ½ patients with MDD recover in 6 months

13. FIGURE 5-1 The Course and Outcome of Major Depression

14. COURSE AND OUTCOME • Bipolar Disorders • Onset usually occurs between 18 and 22 years. • First onset can be depression or mania. • Average duration of a manic episode runs between 2 and 3 months. • Long-term prognosis mixed • Rapid Cyclers—experiencing at least 4 mood episodes within a 12 month period

15. FREQUENCY • Incidence and Prevalence • 16% of NSC-R study (n = 9,000) suffered from depression. • Lifetime risk of for bipolar I and II disorders combined is close to 4%. • Ratio of unipolar to bipolar disorders is at least 5:1.

16. FREQUENCY • Gender Differences • ♀ 2-3x more vulnerable to depression than ♂. • ♀ are more likely than ♂ to present for mental health services. • More difficult for ♂ to admit to subjective feelings of distress. • Gender differences not typically observed for bipolar mood disorders.

17. Do negative life events cause depression? Or does depression lead to negative events? • Major losses of important people or rolesseem to play a crucial role in precipitating major depression. • Depression more likely when life events are associated with feelings of humiliation, entrapment and defeat.

18. CAUSES • Social Factors and Bipolar Disorders • Less attention paid to bipolar disorders • Weeks preceding the onset of a manic episode marked by an increased frequency stressful life events. • Factors different than from depression • Schedule-disrupting events • Goal attainment

19. CAUSES • Psychological Factors: Cognitive vulnerability • Aaron Beck – pervasive and persistent negative thoughts central in the onset of depression when activated by a negative event. • Cognitive Triad • Learned helplessness—Seligman

20. Cognitive Distortions

21. Why do some people become depressed after stressful life events while others do not? • Response Styles and Gender • Ruminative style (women more likely) • Distracting Style (men more likely) • Interpersonal Factors and Social Behaviors • Some depressed people create difficult circumstances, increase the level of stress. • Integration of Cognitive and Interpersonal Factors • Vulnerability to depression influenced by childhood experiences.

22. BIOLOGICAL FACTORS • Genetics • Twin Studies • Genes play a more important role in bipolar disorders • Heritability (0–100): bipolar mood disorders have heritability of 80% • Polygenic • Genetic Risk and Sensitivity to Stress • Gender, “s” allele of the 5-HTT—NO LONGER CITED AS DEFINITIVE

23. FIGURE 5-5 The Hypothalamic- Pituitary-Adrenal (HPA) Axis is activated in response to stress.

24. FIGURE 5-6 Brain regions involved in emotions and mood disorders

25. BIOLOGICAL FACTORS • Neurotransmitters • More than 100 different neurotransmitters in the CNS, and each is associated with several types of postsynaptic receptors. • The 3 most likely to play a role in depression are: Serotonin, Norepinephrine, & Dopamine

26. TREATMENT: UNIPOLAR DISORDERS Cognitive therapy Interpersonal therapy • Cognitive restructuring • Focuses on helping patients replace self-defeating thoughts with more rational statements. • Focuses on current relationships, especially familial • Attempts to improve relationships by building communi-cation & problem-solving skills.

27. TREATMENT • Unipolar Disorders - Antidepressant Medications • Four general categories • Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSNRIs), Tricyclics, Monoamine Oxidase Inhibitors (MOA-Is) • Improvement typically four to six weeks • Current episode often resolved within 12 weeks. • Efficacy – only ~ 50%

28. TREATMENT: UNIPOLAR DISORDERS SSRI’s Tricyclics • Block reuptake of Serotonin • Prozac, Paxil, Zoloft • Most frequently used • Easier to use • Fewer side effects • Sexual dysfunction, weight gain • Less dangerous in event of overdose • Block reuptake of norepinephrine • Imipramine and amitripyline • More side effects: • Constipation, drowsiness, drop in BP, blurred vision • Equal in efficacy as SSRIs

29. TREATMENT: UNIPOLAR DISORDERS SSNRI’s MAO-I: • Effexor, Cymbalta • Block reuptake of both serotonin and norepinephrine • Long term effects less known • Phenelzine (Nardil) • Not as effective tricyclics • Side effects: Consuming foods with tyramine (cheese and chocolate) often increases BP. • Used in treatment of anxiety disorders, particularly agoraphobia and panic.

30. Experimental & Alternative Treatments • Electroconvulsive therapy (ECT) • Electromagnetic Treatments Deep brain stimulation

31. TREATMENT: BIPOLAR DISORDERS Lithium Anti Seizure medications • Effective treatment in alleviation of manic symptoms • 60% of patients improve • Non-compliance with drug due to side effects • Nausea • Weight gain • Memory problems • Mood Stabilizers • Depakot, Tegetrol • Mechanism of how it works is unknown

32. TREATMENT: BIPOLAR DISORDERS Psychotherapy • Can be effective supplement to biological intervention • Combination of psychotherapy and medication is more beneficial than medication alone.

33. SUICIDE • 15 to 20% of all patients with mood disorders will eventually kill themselves.

34. Suicide • S -- Sex • A -- Age • D -- Depression • P – Previous Attempt • E – Ethanol Abuse • R – Rational Thought • S – Social Support • O – Organized Plan • N – No Spouse • S -- Sickness

35. SUICIDE • Classification of Suicide • Nonsuicidal Self-Injury • Deliberate self-harm without desire for suicide: cutting, burning, scratching the skin • Pain serves as useful purpose • To punish the self • Is a reflection of frustration and anger. • Maladaptive way to regulate intense, negative emotional states.

36. SUICIDE • Causes of Suicide • Psychological Factors • Psychological pain: social isolation, feelings of being a burden, previous attempts • Biological Factors • Reduced levels of serotonin: poor impulse control; violent and aggressive behaviors • Potential for genetic predisposition • Social Factors • Availability of guns, media

37. SUICIDE • Treatment of Suicidal People • Crisis Centers and Hotlines • Primarily suicide prevention • Efficacy for “saving lives” not demonstrated • People with most lethal ideations will not call • Offers valuable assistance to people in distress • Psychotherapy • Reduce lethality

38. SUICIDE • Treatment of Suicidal People • Psychotherapy (continued) • Negotiate agreements • Provide support • Replace tunnel vision with a broader perspective • Medication • SSRIs in treating depression lowers suicide rates.