Chp 6/7: Depression & Suicide

Core Symptoms of Major Depressive Disorder

Depressed mood and/or Anhedonia

DSM5 Criteria of MDD?

weight, sleep disturbance, psychomotor, fatigue, worthlessness, concentration and suicide. 5+ symptoms and for 2+ weeks

Psychomotor changes

Agitation: observable restlessness or Retardation: slowed movements or thinking that others can observe

Anxious distress

co-occurring anxiety symptoms

Melancholic features

Severe anhedonia, worse in morning, early awakening, excessive guilt, significant weight loss

Atypical features

Mood reactivity, increased appetite/weight gain, hypersomnia, leaden paralysis, rejection sensitivity

Psychotic features

Hallucinations or delusions (often mood-congruent themes of guilt, disease, or nihilism)

Catatonia

Psychomotor immobility, stupor, or excessive purposeless activity

Peripartum Onset

During pregnancy or within 4 weeks postpartum

Persistent Depressive Disorder (Dysthymia)

Chronic depression lasting ≥2 years with fewer symptoms than Major Depressive Disorder.

Premenstrual Dysphoric Disorder

Severe mood symptoms during luteal phase of menstrual cycle

Disruptive Mood Dysregulation Disorder

Childhood disorder with severe irritability and temper outbursts

Substance/Medication-Induced Depressive Disorder

Depression directly caused by intoxication, withdrawal, or medications

Differential Diagnosis BP

Screen for past manic/hypomanic episodes to avoid mania with antidepressants

Adjustment disorder w/depressed Mood

Time-limited reaction to identifiable stressor

Bereavement vs. MDD

Greif waves of sadness with positive memories vs persistent despair

Medical conditions

Hypothyroidism, vitamin D/B12 deficiencies, anemia can mimic depression

Monoamine hypothesis in MDD?

Deficiency in neurotransmitters such as serotonin, norepinephrine, and dopamine.

Beyond simple depletion

Receptor sensitivity, neurotransmitter synthesis, and breakdown issues

Hippocampus & Prefrontal Cortex

Atrophy linked to memory problems and stress response dysregulation. Reduce activity in executive function & emotion regulation

Amygdala

Hyperactivity leading to heightened emotional Reponses

Default mode network

Increased connectivity associated with rumination (obsessive dwelling on negative aspects)

Beck's cognitive triad theory

A negative view of self, of world, and future.

Cognitive distortions

All-or-nothing, overgeneralization, mental filter (focus only on negatives), catastrophizing “worst thing ever”

Learned helplessness

Belief that actions don't affect outcomes, leading to passive resignation

Rumination

Repetitive focus on symptoms and causes without problem-solving

Behavioral Theories

Loss of reinforcement (reduced pos experiences leading to withdrawal), Social skills deficits, avoidance patterns

Becks Model

Negative schemas activated by stress —> cognitive distortions —> depression

Behavioral activation

Depression as consequences of avoidance and reduced activity

What is the diathesis-stress model?

It combines genetic/biological vulnerability with environmental triggers to explain depression.

What is the Beck Depression Inventory (BDI-II)?

A widely used self-report measure with 21 items that assesses depression with good reliability.

PHQ-9

Brief (9 items), tracks DSM criteria, used in primary care

Hamilton Depression Rating Scale

Clinician-administered, gold standard in research

What is the Columbia Scale used for?

To systematically assess suicide ideation, plans, and attempts.

Cognitive Behavioral Therapy (CBT)

Identifying and changing negative thought patterns and behaviors.

What are the three phases of Interpersonal Therapy (IPT)?

Initial (assessment), middle (working on problem area), termination. Focus on current relations and life circumstances. Equal to CBT with interpersonal triggers

What is the principle behind Behavioral Activation?

Increase rewarding activities to improve mood

Selective Serotonin Reuptake Inhibitors (SSRIs)

Block reuptake of serotonin at synaptic cleft, increasing serotonin availability —> Effects on neuroplasticity and mood regulation . First line of treatment for patients

Side Effects of SSRI & SNRI

nausea, sexual dysfunction, weight gain, anxiety (initial), emotional blunting. Takes 4-6 weeks to have full effect

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Dual reuptake inhibition affecting both serotonin and norepinephrine systems

Tricyclic Antidepressants (TCAs)

Second line medication; block reuptake of serotonin and norepinephrine; also block histamine, acetylcholine, and α1 receptors

MAOIs Inhibitors

Treatment for resistant cases; inhibit enzyme break down of monoamines —> increase NE, Serotonin and DA

What is the mechanism of action for Ketamine/Esketamine?

NMDA receptor antagonist leading to rapid increase in glutamate

What is the classic augmenter for treatment-resistant depression?

Lithium.

Electroconvulsive Therapy (ECT)

Considered the gold standard for severe depression; controlled seizure —> neuroplastic changes ~1 month, ¾ per week

Transcranial Magnetic Stimulation (TMS)

It uses magnetic pulses to stimulate the prefrontal cortex. Non-invasive, no memory loss, outpatient, daily sessions for 4-6 weeks

Vagus Nerve Stimulation (VNS)

It is used for treatment-resistant depression. Modest improves over time

What are common comorbidities associated with depression?

Anxiety disorders, substance use, and medical conditions like diabetes and heart disease.

Suicide

The intentional act of ending one's own life.

Suicidal Ideation

Thinking about, considering, or planning suicide.

Suicide Attempt

A non-fatal, self-directed behavior with intent to die.

Completed Suicide

Death caused by self-directed behavior with intent to die.

Non-Suicidal Self-Injury (NSSI)

Intentional self-harm without suicidal intent (cutting to relieve emotional distress).

Biological Factors

Genetic predisposition, neurochemical imbalances (low serotonin), chronic medical illness or pain.

Psychological Factors

Major depressive disorder, bipolar disorder, schizophrenia, substance use disorders, history of trauma or abuse, hopelessness and cognitive rigidity.

Social/Environmental Factors

Access to lethal means (e.g., firearms, medications), social isolation, lack of support, recent loss (relationship, job, status), bullying or discrimination.

Warning Signs

Talk about harm, gifting possessions, writing a will, withdrawal from friends, family, activities, increased substance use, sudden mood improvement after severe depression.

Crisis Intervention

Suicide hotlines, emergency psychiatric care.

Psychotherapy

Cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT) effective for suicidal ideation and self-harm.

Medication

Antidepressants, mood stabilizers, antipsychotics (as indicated).

Safety Planning

Identifying coping strategies, removing lethal means, creating emergency contacts.

Community Approaches

Public education, reducing stigma, increasing mental health resources.

Lethality (Suicide vs. NSSI)

Suicide: Often high (firearms, overdose); NSSI: Low to moderate (cutting, burning).

Treatment (Suicide vs. NSSI)

Suicide: Crisis stabilization (therapy) ; NSSI: DBT, emotion regulation skills, therapy.