Mood Disorders and Suicide

mood disorders

• characterized by severe disturbances in mood and emotions; most often depression, but also mania and elation 

  • These people also experience mood fluctuations, but their fluctuations are extreme, distort their outlook on life, and impair their ability to function 

  • Symptoms can range from the extreme sadness and hopelessness of depression to the extreme elation and irritability of mania

  • differ from normal mood states in duration and severity

    • lasts for several weeks or more

    • causes extreme distress or impairment in functioning

  • specifiers: course, severity, features, onset

depressive disorders (also called unipolar disorders)

• a group of disorders in which depression (intense and persistent sadness) is the main feature

  • Depressed people feel sad, discouraged, and hopeless; they lose interest in activities once enjoyed, experience a decrease in drives (ex: hunger), and frequently doubt personal worth

• major depressive disorder and persistent depressive disorder (dysthymia)

bipolar and related disorders

• group of disorders in which mania (a state of extreme elation and agitation) is the defining feature

  • When people experience mania, they may become extremely talkative, behave recklessly, or attempt to take on many tasks simultaneously

  • bipolar disorder type I, bipolar disorder type II, Cyclothymia

  • types of episodes: manic, hypomanic, and mixed

major depressive disorder diagnostic criteria

• Presence of a single major depressive episode and no history of a
  manic episode

• MDE – Five or more of the following, within a two week period.

  • Depressed mood, almost every day

  • Markedly diminished interest or pleasure

  • Change in weight (when not dieting) or appetite

  • Insomnia or hypersomnia

  • Psychomotor agitation or retardation

  • Fatigue or loss of energy

  • Feelings of worthlessness, or excessive or inappropriate guilt

  • Diminished ability to think, concentrate, make decisions

  • Recurrent thoughts of death, suicidal ideation (with or without
    specific plan), or suicide attempt

major depressive disorder

• Characterized by a depressed mood most of the day, nearly every day (sad, empty, hopeless), and loss of interest and pleasure in usual/gratifying activities  

• Extremely heterogeneous symptom presentation! Considering all the different combinations of symptoms, there are over 16,000 different possible profiles!

• Lifetime prevalence is 10-25% for women and 5-12% for men

• First episode often occurs following a severe psychosocial stressor, but this is less common for subsequent episodes

• 50% have a comorbid anxiety disorder

• Average age of onset is mid-20s, but this appears to be getting younger

• 60% of people who experience a MDE will experience a second, 70% with two with experience a third, and 90% with three will
  experience a fourth

• 1 year after diagnosis, 40% will still meet criteria for MDD, 20% have symptoms that do not meet criteria, and 40% have no mood
  disorder

• One of the most controversial changes in DSM5 was the removal of the “bereavement exception” for MDD which was in DSM-IV

  • That means that clinicians can now diagnose depression shortly after the death of a loved one, though there are guidelines about when this should be done

persistent depressive disorder (Dysthymia)

• Depressed mood most of the day for at least two years (one year in children), with no more than two months at a time in which criteria are not met

  • Two or more of the following when depressed:

  • Poor appetite or overeating

  • Insomnia or hypersomnia

  • Low energy or fatigue

  • Low self-esteem

  • Poor concentration or difficulty making decisions

  • Feelings of hopelessness

• Female : male ratio is about 1:1 in children and adolescents, but 2-3x more common in women than men in adulthood

• Onset is often early and insidious

• Differentiating between dysthymia and MDE is difficult, as they share many symptoms

  • DD is more chronic and has less severe symptoms

premenstrual dysphoric disorder

• During most menstrual cycles, in the week before onset of menses, a total of five of:

  • One of: mood lability, irritability, depressed mood, or anxiety

  • One of: Decreased interests, problems concentrating, lack of energy, changes in appetite/cravings, changes in sleep, feeling of being overwhelmed, physical symptoms (breast tenderness, joint pain, bloating)

• 1-year prevalence of around 1-2%

• Heritability of about 50%

manic/hypomanic episode

• Period of abnormally and persistently elevated, expansive, or
  irritable mood lasting at least 4 (hypomanic) or 7 (manic)
  days

  • At least three or more, unless mood is irritable (4)

  • Inflated self-esteem or grandiosity

  • Decreased need for sleep

  • More talkative

  • Flight of ideas or racing thoughts

  • Distractibility

  • Increased goal-direct activity or psychomotor agitation

  • Excessive pleasurable activities that have high potential for
    painful consequences (financial, s*xual, etc)

• Hypomanic episode does not cause marked impairment in
  social or occupational functioning, does not require
  hospitalization, and does not have psychotic features

mixed episode

• Period of time lasting at least four days where criteria for Manic episode and Major Depressive episode are both met

• Very rapid cycling of moods, or a mix of extremely high and low emotions

• Sometimes occurs following somatic treatment for unipolar depression (antidepressant medication, phototherapy, ECT), and may make patients more vulnerable to future manic episodes

bipolar disorders

• Bipolar Type I

  • At least one manic or mixed episode

  • Major depressive episode is not required for diagnosis, but most patient have one

• Bipolar Type II

  • Recurrent major depressive episodes with hypomanic episodes

• Cyclothymia

  • Hypomanic episodes with depressive episodes that do not meet criteria for MDE

  • Two year duration

• Prevalence of BD Type 1 is 0.6-0.1%, Type II is 1.1%, cyclothymia is 0.5-2.5%

• Childhood bipolar is a controversial topic!

  • 40% increase in Dx of BP in children between 1994 and 2003

  • Differential diagnoses include severe ADHD, oppositional-defiant disorder, and disruptive mood dysregulation disorder (severe and developmentally inappropriate temper outbursts, and irritability)

specifiers for bipolar and depressive disorders (but mostly depressive)

• With anxious distress

  • Symptoms of general anxiety co-occur with mood symptoms

• Melancholic features

  • Extreme anhedonia (lack of interest to things that typically bring joy) or lack of mood reactivity

  • Despondency, despair

  • Mood worse in the early morning

  • Early awakening

  • Marked psychomotor retardation or agitation

  • Significant weight loss

  • Excessive guilt

• Melancholic depression is associated with a different set of biomarkers compared to other types of depression, involving altered reward processing (limbic-cortical pathways)

• With seasonal pattern (depressive disorders only)

  • Regular temporal relationship between onset of mood symptoms and particular time of the year

  • Not surprisingly, more common at higher latitudes (2-3%
    prevalence in Canada)

• Postpartum onset (depressive disorders only)

  • Onset of episode within 4 weeks postpartum

  • Distinguish from baby-blues (70% of women) which does not
    impair functioning

  • 10-20% of mothers and 10% of fathers

specifiers for bipolar disorders (and also depressive)

• Atypical features (though actually common)

  • Mood reactivity, increased appetite or weight, and hypersomnia

  • Pattern of rejection sensitivity

• Psychotic features

  • Delusions or hallucinations (usually mood congruent, often persecutory)

• Catatonia

  • Motor immobility, excessive pointless motor activity, extreme negativism, posturing, echolalia (repetition of words/phrases spoken by someone else) or echopraxia (imitation of someone’s physical movements or facial expressions)

• Four or more distinct mood episodes in a 12 month period

  • Episodes separated by either full remission or switch to
    opposite pole (MDE to manic)

specifiers for depressive and bipolar disorders: severity

• Mild – only minimally meets criteria

• Moderate – between mild and severe

• Severe – needs near constant supervision to avoid threat of harm to self or others, or has psychotic features

etiology of depressive and bipolar disorders

• Genetics

  • Heritability of MDD estimated at 0.36, while heritability of bipolar disorder estimated at 0.8 or higher

  • The famous (but very incomplete) monoamine hypothesis

    • Insufficient serotonin and other monoamines in the brain, BUT, reductions in serotonin, dopamine, and
      norepinephrine are not always associated with depression

    • SSRIs immediately increase serotonin levels, but depression symptoms take weeks to change

  • stress and deregulation of the HPA axis

  • overlap with marijuana induce amotivational syndrome

  • several brain areas with abnormal activation in major depression:

    • amygdala (abnormal activation)

    • prefrontal cortex (less activation)

    • anterior cingulate (less activation)

    • insula (greater activation)

    • hypothalamus (greater activation)

• childhood and adult attachments - mood disorders more common individuals with insecure and anxious/avoidant attachment styles than those with secure attachment

• cognitive theories

  • maladaptive thoughts (cognitive distortions)

  • schemas may represent a diathesis

• behavioral theories

  • emphasize maintenance of the mood disorder

  • avoidance of pleasurable activities, lacks of assertiveness, habits around sleep/eating/social activity

treatment for depressive and bipolar disorders

• Psychotherapy

  • CBT, interpersonal, and brief psychodynamic therapy are all empirically validated treatments for major depressive disorder

  • Some evidence that CBT and mindfulness-based CBT are more effective at preventing relapse than other treatments

  • Changing automatic thoughts, behaviours, and schemas that maintain and exacerbate depression

• Medication for unipolar depression (efficacy is equivalent, effectiveness depends on the person)

  • Tricyclic antidepressants (TCAs)

  • Monoamine oxidase inhibitors (MAOIs)

  • Selective serotonin re-uptake inhibitors (SSRIs)

  • Serotonin-norepinephrine re-uptake inhibitors
    (SNRIs)

• Combination of medication and psychotherapy

  • In adolescents, chronic depression, or severe depression, a combination of treatments appears to be superior to either treatment alone

• Medications for Bipolar mood disorders

  • Lithium

  • Anticonvulsants

  • Antipsychotics

  • Antidepressants (carefully)

• Other therapies

  • Phototherapy for seasonal mood disorders

  • Electroconvulsive therapy (ECT)

  • Transcranial magnetic stimulation (TMS)

  • Deep brain stimulation (DBS)

suicide

• Worldwide, about one million people die by suicide per year, 10- 20 million attempts

• 11.3 per 100,000 people in Canada

  • 17.8 in males, 5.1 in females

  • Second highest cause of death in people aged 10-24

  • Highest single cause of death in boys 15-19

• In North America, suicide is considerably more common in rural than urban environments

  • Availability of methods, geographical barriers to help seeking, culture of independence, stigma, privacy concerns, economic changes

  • Suicide clusters and suicide pacts

• SAD PERSONS (sex, age, depression, previous attempt, excess alcohol or substance, rational thinking lost, social supports lacking, organized plan, no spouse, sickness)

• <5 is low risk, >6 is high risk

  
  

suicide - definitions

• Suicidal ideation: thoughts of death and/or plans for suicide

• Suicidal gestures: behaviours that look like suicide attempts, but are not life-threatening

• Suicide attempt: carrying out a plan to actually die by suicide, that does not result in death

• Completed suicide: carrying out a suicidal plan that results in death

• Suicide survivors: family, friends, co-workers, professionals involved in care, of someone who completes suicide

suicide and psychological disorders

• Up to 90% of people who die by suicide have a mental illness (70% have MDD; 46% have substance abuse disorders)

• Up to 10% of people with schizophrenia will complete suicide

• Social factors

  • Loss of cultural and social identity in First Nations, intergenerational transmission of trauma

  • Massive social changes in rapidly industrializing countries (China)

  • Relative acceptability of suicide in some cultures (comparing North Americans of European to African ancestry); Indigenous people have higher suicide rates

suicide prevention

• High risk groups

  • Screening, observation and removal of means, specific treatments and interventions (DBT), aggressive treatment or hospitalization?

  • Suicide contracts – safety plans

• patient safety plan template

  • 1. Warning signs (thoughts, images, mood, situation, behavior) that a crisis may be developing

  • 2. Internal coping strategies – Things I can do to take my mind off my problems without contacting another person (relaxation technique, physical activity)

  • 3. People and social settings that provide distraction

  • Step 4: People whom I can ask for help. Names and phones. Doctors, emergencies, hospitals, support lines.

  • Step 5: Professionals or agencies I can contact during a crisis.

  • Step 6: Making the environment safe

• Population based

  • Educational programs and awareness campaigns, encourage appropriate communication/media approaches,
    especially around the deaths of celebrities, restrict means or make means more difficult to use, telephone hotlines

depression attributional scale

• a cognitive-behavioral theory that explains how individuals' attributions about the causes of negative events can influence their mood and behavior

• It posits that people who attribute negative events to internal, stable, and global causes are more likely to develop depression

  • Internality: This dimension determines whether the cause of an event is attributed to factors within oneself (internal) or external factors (external).

  • Stability: This dimension concerns whether the cause is viewed as permanent and enduring (stable) or temporary and changeable (unstable).

  • Globality: This dimension determines if the cause is limited to a specific domain (specific) or influences all aspects of life (global).
    A person's consistent placement along these three dimensions forms their unique explanatory style, which has profound implications for their motivation, resilience, and susceptibility to psychological distress

biological basis of mood disorders

• Genetic factors play a stronger role in bipolar disorder than in MDD 

• People with mood disorders often have imbalances in certain neurotransmitters, particularly norepinephrine and serotonin 

  • These neurotransmitters are important regulators of the bodily functions that are disrupted in mood disorders, including appetite, sex drive, sleep, arousal, and mood  

  • Medications that are used to treat MDD typically boost serotonin and norepinephrine activity, whereas lithium, which is used in the treatment of bipolar disorder, blocks norepinephrine activity at the synapses  

• Depression is linked to abnormal activity in several regions of the brain, including those important in assessing the emotional significance of stimuli and experiencing emotions (amygdala), and in regulating and controlling emotions (like the prefrontal cortex)  

  • Depressed people show elevated amygdala activity, especially when presented with negative emotional stimuli  

  • Depressed people exhibit less activation in the prefrontal, particularly on the left side  

    • Because the prefrontal cortex can dampen amygdala activation, thereby enabling one to suppress negative emotions, decreased activation in certain regions of the PFC may inhibit its ability to override negative emotions that might then lead to more negative mood states  

  • Abnormal elevated levels of cortisol, which is a stress hormone released into the blood by the neuroendocrine system during times of stress  

    • High levels of cortisol are a risk factor for future depression, and cortisol activates activity in the amygdala while deactivating activity in the prefrontal cortex  

diathesis-stress model and major depressive disorders

• proposes that depression is triggered by a cognitive vulnerability (negative and maladaptive thinking) and by precipitating stressful life events  

• Stressful life events can trigger depression, especially exit events (instances in which an important person departs, such as death, divorce, etc.) 

  • Exit events are especially likely to trigger depression if these happenings occur in a way that humiliates or devalues the individual  

• People who are exposed to traumatic stress during childhood are at a heightened risk of developing depression at any point in their lives  

• Which predispositions could cause depression? 

  • An alteration in a specific gene that regulates serotonin (5-HTTLPR gene)  might be one culprit  

    • If a person experienced a stressful life event and carried one or two short versions of this gene, instead of the two long versions, then they were more likely to be depressed  

    • However, if the person didn't experience a stressful life event, and had one or two short versions of the gene, then they were unlikely to experience episodes of depression  

    • People experiencing chronic depression in adulthood suggests a much higher incidence in individuals with a short version of the gene in combination with childhood maltreatment  

Aaron Beck’s cognitive theory

• depression-prone people possess depressive schemas, or mental predispositions, to think about most things in a negative way 

  • This dysfunctional style of thinking is maintained by cognitive biases, or error in how we process information about ourselves, which lead us to focus on negative aspects of experiences, interpret things negatively, and block positive memories  

  • Ex: a person whose depressive schema consists of a time of rejection might be overly attentive to social cues of rejection and he might interpret this cue as a sign of rejection and automatically remember past incidents of rejection 

hopelessness theory

• postulates that a particular style of negative thinking leads to a sense of hopelessness, which then leads to depression 

  • Hopelessness stems from a tendency to perceive negative life events as having stable ("it's never going to change") and global ("It's going to affect my whole life") causes, in contrast to unstable ("it's fixable") and specific ("It applies only to this particular situation") causes, especially if these negative life events occur in important life realms, such as relationships, academic achievement, and the like  

  • People who exhibit this cognitive style in response to undesirable life events will view such events as having negative implications for their future and self-worth, thereby increasing the likelihood of hopelessness – the primary cause of depression  

other cognitive theory

• focuses on how people's thoughts about their distressed moods – depressed symptoms in particular – can increase the risk and duration of depression  

  • This theory focuses on rumination, which is the repetitive and passive focus on the fact that one is depressed and dwelling on depressed symptoms, rather than distracting one's self from the symptoms or attempting to address them in an active, problem-solving manner  

  • This theory is used to explain the higher rates of depression in women than in men because women are more likely to ruminate