MOOD DISORDERS (unipolar/depression, and bipolar) AND SUICIDE (ch 5)

washu psychopathology and mental health chapter 5 of psych texbook

terms for depression

depression, major depressive disorder (MDD), unipolar depression

DSM-V criteria for a major depressive disorder

must meet at least 5 of the following during the same 2-week period. at least one must be 1) depressed mood or (2) loss of interest or pleasure (anhedonia)

1. depressed mood most of the day, nearly every day, as indicated by self report of observations made by others — NOTE (in children or adolescents an be irritable mood)

2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3. significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. (a change of more than 5% of body weight in a month)

4. insomnia or hypersomnia nearly every day

5. psychomotor agitation or retardation nearly every day (observable by others)

6. fatigue or loss of energy nearly every day

7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day

8. diminished ability to think or concentrate, or indecisiveness, nearly every day

9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide

major depressive disorder criteria:

• at least one major depressive episode

• no manic or unequivocal hypomanic episodes

dysthymic disorder

low level mood for an extended period of time:

• depressed mood for at least 2 years

• never without these symptoms for more than 2 months within this 2-year period

• no major depressive episode during the first 2 years

• lifetime prevalence = 3%

lifetime prevalence of dysthymic disorder

3%

premenstrual dysphoric disorder (PMDD) — new DSM-5 diagnosis

for most menstrual cycles over the past year; 5 or more symptoms present during luteal phase that begin to remit following menses

prolonged grief disorder — new DSM-5 diagnosis

continued presence, for at least 12 months after the death of a loved one, of impairing symptoms associated w grief

unspecified mood disorder — new DSM-5 diagnosis

a residual category for presentations of mood symptoms that don’t meet full criteria for any of the disorders in either the bipolar of the depressive disorders diagnostic classes

depression and additional mood disorder specifiers: “with psychotic features”

depression w psychotic features = hallucinations or delusions; mood congruent; only happens during depressive episodes

depression and additional mood disorder specifiers: “chronic major depressive disorder”

depression that does not remit for > 2 years

depression and additional mood disorder specifiers: “seasonal affective disorder”

recurrent episodes with a seasonal pattern

• common pattern = when days get shorter / less light —> more depression

depression epidemiology:

• lifetime prevalence of MDD = 16-17%

• 16-17 year olds (adolescents) have the highest rate of MDD

• major depression is the leading cause of disability (10%)

• age onset = adolescence and young adulthood

  • earlier onset = more severe

birth cohort trend for depression

prevalence is much higher in recent generations

why? we dont know. maybe awareness, technology, etc?

gender and depression

MDD: 2x as common in women relative to men

why?

• women more liekly to present at health clinics, disclose feelings, seek treatment

• men more likely to deal w in more externalizing ways (ex alcohol use). women externalize ore

• rumination vs distraction

depression across cultures

universal phenomenon, but each culture expresses differently

• ex: china and japan: more likely to be described in terms of somatic complaints (sleeping problems, headaches, loss of energy, stomach issues)

depression recovery

remission = period of recovery

• full remission = at least 2 months with no significant depressive symptoms

• partial remission = some symptoms, but no longer meet full criteria

relapse = return of active symptoms

statistic: 50% recover in 6 months

depression environmental factors

• stressful life events

• lack of social support

• chronic stress

depression biological factors

• HPA axis

• genetic vulnerability

• brain function

• neurochemicals

depression psychological factors

• information processing bias

• cognitive distortions

• rumination

• personality / temperament

effects of uncontrollable stress on rats — depression study

• induces a condition that resembles depression

• depletion of: norepinephrine, serotonin, dopamine

HPA axis: hypothalamic pituitary adrenal axis

individuals with depression: release a lot more CRF (corticotropin releasing factor) from their hypothalamus which stimulates more cotricotropin release form anterior pituitary which stimulates more cortisol release from adrenal cortex.

cortisol released into bloodstream and supports fight or flight responses.

gene x environment interaction in depression

• serotonin transporter gene = 5HTTLPR

  • short (s) allele = associated w increased risk of depression

  • long (l) allele not associated

  • homozygous for short allele at greatest risk for depression, especially if experience high stress event

• twin studies: 30% increase with severity

  • 1/3 of risk is attributed to genetics

brain regions associated with depression

decreased functioning of:

• orbital frontal cortex (OFC): related to reward functioning and how we respond to

• ventral striatum: decision making functions and motor control

• dorsolateral prefrontal cortex: cognitive control

• Anterior cingulate cortex: selective attention

• hippocampus (volume): learning and memory

increased functioning of:

• amygdala: emotion and threat, fear

depression and reward

depressed individuals reacted less to both penalties and reward stimulus when compared to a normal control group. Shows reward center hypoactivation.

cognitive vulnerability to depression — why some individuals become depressed after stressful life events and some do not

• pervasive and persistent negative thoughts about the self

• pessimistic view of the environment

• these thoughts are activated by the experience of negative life events

becks’ negative cognitive triad

triad of the self, the world, and the future

early negative life experiences —> formation of dysfunctional beliefs —> critical incidents —> beliefs activated —> negative automatic thoughts ←→ symptoms of depression

cognitive distortions (becks negative cognitive triad)

• negative attribution style: internal, global, stable way of thinking ab the world; consistently views world in negative way or think that world views u in negative way

• negative schemata: tend to view the world negatively and process info in negative ways as a result

• rumination

negative automatic thoughts (Beck’s negative cognitive triad)

• emerge automatically; rapid duration

• not fully conscious

• often occur in shorthand

• not a result of deliberation, reasoning, or reflection

• reflexive

• difficult to turn off

• validity is accepted without question

• often precede a powerful emotion

treatment of depression

• cognitive therapy / CBT

• interpersonal therapy

• behavioral activation treatement (CBT)

• antidepressant medication

  • SSRI

  • SNRI

  • MAOI

  • TCA

• alternative treatments

  • ketamine / psilocybin

  • deep brain stimulation

  • electroconvulsive therapy (ECT)

  • transcranial magnetic stimulation (TMS) — prelim data shows that increasing prefrontal cortex activity can help w depression. however TMS doesn’t reach deep brain structures well like ECT

  • bright light therapy for SAD — shown to be just as affective as fluoxetine

cognitive therapy for depression

• focuses on identifying and replacing self-defeating thoughts with rational statements

• deal w current experiences

• effective for unipolar depression

interpersonal therapy for depression

• focus on current relationships and attempts to improve these relationships via building communication and problem solving skills

• idea: improved support system may improve depressive symptoms

behavioral activation treatment for depression

• plan positive activities; force individual to get up and go

• for indivs. who are severely depressed, just do one thing a week (ex. get out of bed and take a shower)

• works very well with meds. not as affective without combination w meds tho.

four classes of antidepressant medication

SSRI: selective serotonin reuptake inhibitor (** current pref method)

SNRI: serotonin and norepinephrine reuptake inhibitor

MAOI: monamine oxidase inhibitors

• inhibit enzymes that break down serotonin and norepinephrine

TCA: tricyclic antidepressants

• inhibit norepinephrine reuptake (also serotonin tho lesser)

SSRI specifics

• positive response: 50% or larger reduction of symptoms

• remission: complete and sustained recovery

• 50% of patients show a pos response following 3-5 wks of treatment

• prozac, paxil, zoloft

• (also used for anxiety, OCD, bulimia, borderline personality disorder)

• issues: nausea, insomnia, sexual problems

suicide relation to mental disorders

• vast majority of ppl w mental disorders do not die by suicide

• sociodemographic characteristics and stressful life events better predictors of suicide than mental disorders

• risk factors: ppl experience crises, violence, abuse, loss, or isolation. also vulnerable groups that experience discrimination; refugees

• at least 50% of suicides occur in the context of clinical depression

• 15-20% of depressed patients eventually commit suicide

• many other disorders (schizophrenia, alcoholism) associated w higher suicide risk

active vs passive suicidal ideation

active: “I want to kill myself”

passive: “I don’t want to be alive. It would be better if I wasn’t here”

epidemiology of suicide

• suicide rate: 12/100,000

• highest completion rate: white men over 50

• suicide rate increasing for: adolescents

• between 1960 and 1980, completion rate tripled for males 15-24 (doubled for females)

suicide attempts vs completions statistics

in general: attempts to completions ratio = 10:1

among adolescents = 100:1

ages 15-19: females make 3 times as many attempts

male attempts use more lethal/destructive methods

Durkheim’s classifications: the 4 types of suicides

• egotistic: individuals feel alienated and lost

• altruistic: sacrifice for society (“im a burden, im doing this for others”)

• anomic: breakdown of social order (“society is falling apart. this is my reaction”)

• fatalistic: unbearable life circumstances (“life is unbearable, this is the only solution”)

Schneidman’s common elements of suicide

1. purpose: to seek a solution

2. goal: cessation of consciousness

3. Cognitive state: ambivalence

4. Perceptual state: constriction

5. Interpersonal act: communication of intention

   • Not always the case, especially for adolescents. Often an impulsive component

6. Pattern: consistency of lifelong styles

psychosocial factors associated with suicide

• impulsivity

  • one of the main predictors of a suicide attempt. strongly associated w increased attempts compared to ideation

• aggression

• pessimism

• family psychopathology or instability

• genetics

• sociocultural factors

prevalence of suicidal ideation

• 24% of high school girls and 15% of high school boys have serious suicidal thoughts

• suicidal thoughts especially common amongst depressed adolescents

warning signs for student suicide

• depressed and withdrawn

• lowered self esteem

• deterioration of personal hygiene

• loss of interest in studies

• communication of distress

• students who have completed suicide attempts:

  • tend to be doing well in school

  • have low self esteem if academics are involved

  • have compromised interpersonal relationships

  • some significant life event / stressor

predictors of suicidal ideation in students: sex specific effects

men and women:

• felt depressed and hopeless during the last year

men specifically:

• experienced assault in the last year

women:

• 30 days of alcohol consumption

• sexually assaulted

Klonsky’s Framework: From ideation to action (suicide)

• two stages of suicide: ideation, attempts

• different explanations for the two stages

  • pain, connectedness, and means

  • only when your have significant pain, significant loss of connectedness, and the means to do so, do you go from ideation to attempt

• most people (~40%) with suicide ideation do not attempt

• things that predict ideation do not always predict attempts

Thomas Joiner’s approach to suicide:

• “perceived burdensomeness”

• “thwarted belongingness” (social isolation)

• acquired ability to inflict lethal self injury

mood disorder

an umbrella term that encompasses unipolar and bipolar disorders

disorders made up of episodes:

• depressive episodes

• manic episodes

• hypomanic episodes

• mixed episodes

mood disorders are made up of episodes

• depressive episodes

• manic episodes

• hypomanic episodes

• mixed episodes

the manic-depressive spectrum

bipolar I criteria

• at least one full manic (or mixed) episode

bipolar II criteria

• at least one major depressive episode

• at least one hypomanic episode

  • no manic episodes

cyclothymia / cyclothymic disordercriteria

• no manic or major depressive episodes for at least 2 years

• rapid fluctuations in mood, but minor fluctuations (never the extremes of full manic or depressive episode)

• lacks severe symptoms and psychotic features of bipolar

• much less prevalent

criteria for a manic episode

• a period of elevated, expansive, or irritable mood

• lasts at least a week

• at least 3 of the following: DIG FAST mnemonic

  • Distractibility

  • Irresponsibility / irritability — excessive risky pleasure seeking

  • Grandiosity

  • Flight of ideas

  • Activity — goal directed / agitation

  • Sleep decreased

  • Talkativeness — disorganized

• characterized by significant distress or impairment

• often some psychotic symptoms — most often grandiosity

prevalence of mood disorders

• depression = 16-17%

  • dysthymia = ~3%

• bipolar = ~4%

  • bipolar I less prevalent than bipolar II

  • cyclothymia = ~1%

epidemiology of bipolar disorder

• occurs equally btwn males and females

• age of onset: 22 years old avg. ( adolescence or young adulthood )

• days depressed vs days manic: 3 times as many days are depressed as are manic/hypomanic

unipolar vs bipolar comparison

Unipolar:

• Later onset

• More prevalent in women

• Responds to psychotherapy alone, tricyclic or SSRI antidepressant drugs alone, or combination

Bipolar:

• Earlier onset

• Equal prevalence among men and women

• Responds best to lithium carbonate or other mood stabilizers; does NOT respond to psychotherapy alone

environmental risk factors — bipolar disorder

• Stressful life events (HPA axis alteration)

• Goal attainment (high)

• Schedule disruption

  • Very important risk factor for relapse.

• Lack of sleep -- more unique to manic.

  • Not only are they sleeping less. During manic episodes, also say that they require less sleep

  • Also common that prior to the manic episode, they notice they are getting less sleep

biological risk factors — bipolar disorder

• Genetic vulnerability

  • Bipolar is HIGHLY HERITABLE — even moreso than schizophrenia

• Brain function

psychological factors — bipolar disorder

• cognitive distortions

• grandiose thinking

genetics and bipolar disorder

• twin studies found bipolar to be highly heritable (High MZ concordance rates)

• genome-wide association study (GWAS) finds CACNA1C gene snp associated with bipolar

  • gene codes for subunit of the L-type calcium channel involved in general action potentials. associated w increased rates of bipolar

brain function associated with bipolar (reward circuitry)

• hypoactivation of reward circuit to small gains

• hyperactivated amygdala: heightened emotional state → mania

• hypoactivated hippocampus and prefrontal cortex: decrease in rational decision making

• ppl w mania require more stimulation to get activation of their reward system (Right ventral striatum)

treatment of bipolar disorders

lithium:

• effective for mania

• 40% do NOT improve

• side effects that lead to → noncompliance

anticonvulsants:

• tegretol, depakene

• ~50% respond

• used for rapid cycling

• less severe side effects (gastrointestinal)

psychotherapy:

• can supplement medication

• NOT effective alone

• cognitive therapy

• combo of psychotherapy and medication works better than medication alone!!