2. chapter 8 Mood Disorders, Treatment, and Suicide.

Course Overview

  • PSYO 343: Mood Disorders
  • Instructor: Dr. Michelle St. Pierre, R.Psych.

Social Media Commentary

  • Jordan Lancaster's Tweet: Commenting on generational differences in attitudes towards therapy.
    • Boomers: Surprise at the mention of therapy.
    • Millennials/Gen Z: Open discussion about therapy experiences.
    • Engagement: 10.6K Retweets, 42K Likes

Understanding Mood Disorders

Major Depressive Episode

  • Definition: Severe depression characterized by a loss of interest or pleasure in most activities along with cognitive symptoms.
  • Duration: Symptoms last at least two weeks.
    • Symptoms include:
      • General loss of interest
      • Anhedonia: Inability to experience pleasure.
      • Behavioral and emotional shutdown.
      • Feelings of worthlessness.
      • Altered sleep patterns.
      • Appetite changes leading to weight fluctuations.
      • Significant loss of energy.
      • Slowness in physical and mental activity.
      • Fatigue.
      • Concentration difficulties.
      • Suicidal thoughts.

Mania and Hypomania

  • Mania: Extreme pleasure in all activities.
  • Hypomanic Episode: Less severe than a manic episode.
    • Criteria:
      • Minimum of 4 days duration.
      • Symptoms include hyperactivity, rapid speech, and ideas racing.
      • May require hospitalization if manic episode lasts 7+ days.

Structure of Mood Disorders

  • Unipolar Mood Disorder: Mood remains at one pole (depression).
  • Bipolar Mood Disorder: Mood fluctuates between depression and elation.
  • Mixed Features: Presence of mixed symptoms from both poles.

Depressive Disorders

Major Depressive Disorder (MDD)

  • Criteria: Must experience at least five of the following symptoms in a two-week period, with either depressed mood or anhedonia as one symptom:
    1. Depressed mood most of the day, every day.
    2. Diminished interest or pleasure in most activities.
    3. Significant weight change or appetite disturbance.
    4. Insomnia or hypersomnia.
    5. Psychomotor agitation or retardation.
    6. Fatigue or loss of energy.
    7. Feelings of worthlessness or excessive guilt.
    8. Problems with concentration and indecisiveness.
    9. Recurrent thoughts of death or suicidal ideation.
  • No previous manic or hypomanic episodes required.

Persistent Depressive Disorder (PDD)

  • Criteria: A. Persistent depressed mood for 2+ years. B. While depressed, must exhibit at least two additional symptoms. C. Symptoms must never be absent for more than 2 months.
    • Symptoms include poor appetite or overeating, hypersomnia, low energy, poor concentration, hopelessness, and low self-esteem.
    • Double Depression: Occurrence of major depressive episodes within persistent depressive disorder.

Depressive Disorder Specifiers

  • Definition: Additional symptoms that may accompany a depressive disorder.
  • Types:
    • Single or recurrent episode
    • Severity: mild, moderate, severe
    • Additional eight specifiers that help define the symptoms:
    1. With psychotic features
    2. With anxious distress
    3. With mixed features
    4. With melancholic features
    5. With atypical features
    6. With catatonic features
    7. With peripartum onset
    8. With seasonal pattern
    • Example: Major Depressive Disorder, moderate, partial remission, with anxious distress.

Onset and Duration

  • Average onset: Approximately 25 years.
  • Increasing prevalence among adolescents, especially girls.
  • Overall prevalence:
    • 0.07% in children.
    • 3%-6% in adults.
  • PDD may persist for decades, with transgender youth showing 4x higher rates of depression.

Grief and Depression

  • Grief: Experiencing the death of a loved one can lead to depressive symptoms.
  • Types of Grief:
    • Integrated grief
    • Complicated grief
    • Prolonged Grief Disorder (added to DSM-5-TR in March 2022)

Other Depressive Disorders

  • Premenstrual Dysphoric Disorder (PMDD): Severe mood swings and physical symptoms during menstruation.
    • Requires tracking symptoms for two cycles for diagnosis.
    • Prevalence: 5.5%, highly comorbid with MDD.
  • Disruptive Mood Dysregulation Disorder: Characterized by chronic irritability and temper tantrums in children ages 6-18.

Bipolar Disorders

Types of Bipolar Disorders

  • Bipolar I Disorder: Characterized by at least one manic episode, may include depressive episodes.
  • Bipolar II Disorder: Characterized by one hypomanic episode and one major depressive episode. No full mania.
  • Cyclothymic Disorder: Chronic mood fluctuations not meeting the full criteria for bipolar disorder.

Manic Episode Criteria

  • Characteristics: A. Persistently elevated, expansive, or irritable mood lasting 1+ weeks. B. Must have 3+ symptoms (4 if irritable):
    • Inflated self-esteem/grandiosity
    • Decreased need for sleep
    • More talkative or pressured speech
    • Flight of ideas or racing thoughts
    • Distractibility
    • Increased goal-directed activity
    • Involvement in high-risk activities.

Onset and Duration of Bipolar Disorders

  • Bipolar I Disorder Average Onset: 18 years.
  • Bipolar II Disorder Average Onset: 22 years (10%-13% progress to Bipolar I).
  • Suicide Risk: Increased with diagnosis; 60% of cyclothymic patients are women with early onset.

Prevalence of Mood Disorders

  • Statistics:
    • 2.6 million Canadians report mood disorders (CCHS, 2017).
    • Worldwide prevalence: 16% lifetime, 6% in the previous year.
  • Lifetime Prevalence of Bipolar Disorder: 11% in transgender populations.
  • Women are twice as likely to have depression; equal prevalence in bipolar I and II.

Cultural Influences

  • Cultural Differences:
    • Somatic symptoms are more universal; subjective experiences vary by culture.
    • Individualistic cultures emphasize personal feelings (e.g., inadequacy).
    • Collectivist cultures may manifest symptoms via physical complaints.
    • In Canada: Moderate occurrence with 8% prevalence; Indigenous Peoples show 3x-4x higher rates than general population.

Causes of Mood Disorders

Family & Genetic Factors

  • Mood disorders can have familial links, being approximately 2x-3x higher in first-degree relatives.
  • Genetic heritability of mood disorders: around 37% for depression.
  • Joint Heritability: Links between depression, anxiety, and panic disorders.

Neurobiological Factors

Serotonin Hypothesis

  • Low levels of serotonin are thought to influence mood stability.
  • Notable Issue: Serotonin does not cross the blood-brain barrier, complicating direct measurements and theories.

Sleep & Circadian Rhythms

  • Individuals with depression may have altered REM sleep patterns, experiencing quicker onset and increased intensity.
  • Consequences of disrupted sleep: Impact on overall health and well-being.

Psychological Factors

Stressful Life Events

  • 60%-80% of depression cases are linked to past psychological stressors, especially involving negative event interpretations.
  • Gene-Environment Correlation Model: Suggests stressful events can both trigger and worsen depressive episodes.

Learned Helplessness Theory

  • Proposed by Seligman: Individuals may become depressed when they perceive themselves as having no control over their circumstances.
  • Cognitive Attribution: Characterized by negative, internal, stable, and global perspectives on their experiences.

Negative Cognitive Styles

  • Cognitive Distortions: Beck's theory on depression indicates negative interpretations of daily events.
    • Cognitive errors: Arbitrary inference, overgeneralization.
    • Cognitive triad: Negative views about oneself, the world, and the future.

Mood Disorders in Women

  • Women account for 70% of major depressive and persistent depressive disorders.
  • Contributing Factors: Societal roles, feelings of uncontrollability, rumination, poverty, single parenthood, and history of abuse.

The Impact of Social Support

  • Individuals living alone have an 80% higher rate of depression compared to those with social support.
  • Effects of Social Support: Enhances recovery speed from depressive episodes and postpartum depression, but not necessarily from mania.

Treatment of Mood Disorders

Treatment for Depression

Cognitive Behavioural Therapy (CBT)

  • Focuses on correcting cognitive errors and promoting realistic thinking.
  • Techniques include: monitoring thoughts, Socratic questioning, cognitive restructuring, and behavior activation.

Interpersonal Psychotherapy (IPT)

  • Structured and time-limited form of therapy.
  • Explores the influence of relationships and life events on mood.
  • Targets interpersonal problems: grief, role disputes, role transitions, and interpersonal deficits.
  • Goal: Improve relationships and mitigate depressive symptoms.

Alternative Treatments for Depression

  • Electroconvulsive Therapy (ECT): Usually a last-resort treatment, but can be effective and safe.
  • Transcranial Magnetic Stimulation (TMS): Efficacious in treating depression.
  • Ketamine: Emerging research supports rapid antidepressant and anti-suicidal effects.
    • Citation: Walsh et al., 2022.

Psilocybin Research

  • Recent trials showcase psilocybin's antidepressant effects comparable to traditional SSRIs (like escitalopram).
  • Therapeutic Effect: Dose-dependent on mystical experiences during use (Carhartt-Harris et al., 2021).
  • Currently still under research.

Psychosocial Treatments for Bipolar Disorders

  • Interpersonal and Social Rhythm Therapy (IPSRT): Focuses on stabilizing social and biological rhythms alongside medication.
  • Family-focused Treatment: Combined approach with medications.
  • CBT: Identified as effective for bipolar disorder intervention.

Medications for Mood Disorders

  • Classes of Antidepressants:
    • Tricyclics: Older class of antidepressants with diverse side effects.
    • MAOIs: Monoamine oxidase inhibitors, used less frequently due to interaction concerns.
    • SSRIs: Selective serotonin reuptake inhibitors, commonly prescribed for depression.
  • Bipolar Treatment: Lithium is a mood stabilizer effective for preventing/managing manic episodes, utilized in approximately 50% of bipolar patients.

Understanding Suicide

Key Statistics

  • Approximately 800,000 individuals globally die by suicide annually (WHO, 2014).
    • Distinction between suicidal ideation (thoughts) and attempts (survival).
    • Higher incidence rates among Indigenous Peoples, seniors, males, and LGBTQ+ individuals.
  • Patterns of suicidal ideation during and post-pandemic (2.44% in Canada in 2021) were similar to pre-pandemic levels (2.73% in 2019).

Risk Factors for Suicide

  • Family History: A family member with a history of suicide increases risk factors.
  • Existing Psychological Disorders:
    • 90% of individuals who die by suicide have recognized psychological disorders.
    • 60% can be linked to mood disorders, often combined with hopelessness and substance abuse.
    • Stigmas surrounding mental health can exacerbate risks.

Life Events and Vulnerabilities

  • Severe stressors contribute significantly to suicide risk:
    • Experiences of shame, humiliation, abusive environments, or natural disasters.
    • Presence of vulnerabilities, inadequate social support, and a lack of coping mechanisms.

Assessment and Prevention

  • Importance of assessing suicidal ideation.
  • Suicide prevention initiatives include:
    • Crisis centres and intervention resources.
    • Cognitive-behavioral interventions and coping strategy development.
    • Stress reduction techniques.
    • Crisis Text Service: Text CONNECT to 686868 for assistance.