Understanding Mood Disorders

• What makes a mood disorder so hard to understand?

  • Feelings of depression (and joy) are universal, many people experience downs in their life.

• What makes them different from just “feeling sad sometimes”?

  • Feelings are outside the boundaries of normal experience because of intensity and duration.

• Mood Disorders are so incapacitating that violent suicide may seem by far a better option than living

Here is insight on Mood Disorder at play. Consider the Case of Katie:

• In addition to depression, Katie had considerable social anxiety for several years.

• Going to school was difficult for her

• She lost social contacts which attributed to her days becoming empty and dull

• Katie reported thoughts of suicide to a Psychologist in the presence of her parents, which caused them to sob uncontrollably.

  • The sight of their tears deeply affected Katie, and from that point on, she never expressed her suicidal thoughts again, though they remained with her.

By the time she was 16, a deep, all encompassing depression blocked the sun from her life. Here is how she described having depression after receiving successful treatment:

“The experience of depression is like falling into a deep, dark hole that you cannot climb out of. You scream as you fall, but it seems like no one hears you. Some days you float upward without even trying; on other days, you wish that you would hit bottom so that you would never fall again. Depression affects the way you interpret events. It influences the way you see yourself and the way you see other people. I remember looking in the mirror and thinking that I was the ugliest creature in the world. Later in life, when some of these ideas would come back, I learned to remind myself that I did not have those thoughts yesterday and chances were that I would not have them tomorrow or the next day. It is a little like waiting for a change in the weather.”

Before treatment, Katie had no better perspective and was incapable of fighting off depressive thoughts.

• Katie often cried for hours every night

• She began drinking alcohol because it had a temporary soothing effect on her.

  • Her parents were complicit, allowing a glass of wine at dinner; desperate to help their child since medication did not work.

  • Little to their knowledge, Katie was drinking more than one glass of wine at dinner. She secretly began abusing alcohol by:

    • Drinking herself to sleep; as a means to escape her feelings and cloud constant negative thoughts.

      • ““I had very little hope of positive change. I do not think that anyone close to me was hopeful, either. I was angry, cynical, and in a great deal of emotional pain.'“

• Katie’s life continued to spiral downwards as she abused alcohol.

• At this point, her preoccupation with her own death had increased.

  • Katie’s Suicide Attempt:

    • “I think this was just exhaustion. I was tired of dealing with the anxiety and depression, day in and day out. Soon I found myself trying to sever the few interpersonal connections that I did have, with my closest friends, with my mother, and my oldest brother. I was almost impossible to talk to. I was angry and frustrated all the time. One day I went over the edge. My mother and I had a disagreement about some unimportant little thing. I went to my bedroom where I kept a bottle of whiskey or vodka or whatever I was drinking at the time. I drank as much as I could until I could pinch myself as hard as I could and feel nothing. Then I got out a very sharp knife that I had been saving and slashed my wrist deeply. I did not feel anything but the warmth of the blood running from my wrist. The blood poured out onto the floor next to the bed that I was lying on. The sudden thought hit me that I had failed, that this was not enough to cause my death. I got up from the bed and began to laugh. I tried to stop the bleeding with some tissues. I stayed calm and frighteningly pleasant. I walked to the kitchen and called my mother. I cannot imagine how she felt when she saw my shirt and pants covered in blood. She was amazingly calm. She asked to see the cut and said that it was not going to stop bleeding on its own and that I needed to go to the doctor immediately. I remember as the doctor shot novocaine into the cut he remarked that I must have used an anesthetic before cutting myself. I never felt the shot or the stitches.”

  • After this first attempt, her suicidal thoughts became more frequent and real. Her preoccupation with death continued.

Conclusion:

• Katie had a diagnosis of ‘Severe (Clinical) Depression’ that interfered substantially with her ability to function.

  • As you can see, a number of psychological and physical symptoms accompany clinical depression.

An Overview of Depression and Mania

• The Disorders described in this chapter are grouped under the heading ‘Mood Disorders’ because they are characterized by gross deviations in mood.

  • Mood Disorders: Group of disorders involving severe and enduring disturbances in emotionality ranging from elation to severe depression.

The fundamental experiences of depression and mania contribute, either singly or together, to all the mood disorders.

Brief Vocab:

EPISODE VS COURSE

• A ‘Mood Episode’ is a period of time when someone experiences intense emotional states that affect their mood, energy, and ability to function.

  • Mood episodes can be categorized as manic, depressive, or mixed

Depression - the first fundamental state

• Cognitive/Emotional Symptoms

  • Feelings of worthlessness

  • Indecisiveness

  • General loss of interest in activities

  • Inability to experience pleasure from life, including:

    • Social interactions (family, friends)

    • Accomplishments (work, school)

  • Anhedonia (loss of energy, inability to engage in pleasurable activities or have fun)

  • Reflects low positive affect rather than high negative affect

• Physical Symptoms

  • Altered sleeping patterns

  • Significant changes in appetite and weight

  • Notable loss of energy (somatic or vegetative symptoms)

  • Overwhelming effort required for even minimal activity

  • Low behavioral activation (“shutdown”)

  • Crying frequency does not indicate severity or presence of depression

    • ** most central indicators of a full major depressive episode are the physical changes (sometimes called somatic or vegetative symptoms), along with the behavioral and emotional “shutdown,” as reflected by low behavioral activation

• Duration and Diagnosis

  • Symptoms must persist for 2 weeks to be diagnosed

  • Untreated episode lasts approximately 4 to 9 months

Mania - the second fundamental state

• Definition of Mania

  • Mania is a fundamental state in mood disorders characterized by abnormally exaggerated elation, joy, or euphoria. Individuals experiencing mania find extreme pleasure in every activity, with some comparing the sensation to a continuous sexual orgasm.

• Cognitive and Emotional Symptoms

  • Abnormally exaggerated elation, joy, or euphoria

  • Extreme pleasure in every activity

  • Grandiose plans and beliefs in accomplishing anything they desire

  • Rapid, incoherent speech due to “flight of ideas” (attempting to express multiple exciting thoughts simultaneously)

  • Irritability, often appearing near the end of the episode

  • Anxious or depressive feelings can paradoxically accompany mania

• Physical Symptoms

  • Hyperactivity (extraordinary activity levels)

  • Sleepless — Minimal need for sleep

  • Persistently increased goal-directed activity or energy (a defining feature in DSM-5)

  • Self-destructive behaviors (e.g., impulsive buying sprees)

• Duration and Severity

  • Episode duration is at least 1 week (or less if hospitalization is required)

  • Untreated episode may last typically 3 to 4 months

    • Hypomania: Less severe mania

      • episode duration may last at least 4 days, without causing marked impairment in social and occupational functioning

The Different Structures of Mood Disorders

• Unipolar Mood Disorder

  • Defined as experiencing either depression or mania alone, remaining at one “pole” of the depression–mania continuum.

    • EX: Unipolar Mania:

      • Mania alone is rare but possible, as most individuals eventually develop depression.

      • Manic episodes without depression are slightly more common in adolescents.

• Bipolar Mood Disorder

  • Defined as alternating between depression and mania, bouncing between one “pole” of the depression–elation continuum to the other.

  • Though related, depression and elation can occur relatively independently.

    • Example: A person can have manic symptoms but feel somewhat depressed or anxious or be depressed with some symptoms of mania.

  • Bipolar Disorder is an Evolving Condition

    • Bipolar disorder is increasingly viewed as an evolving condition with early mild symptoms that may progress into a chronic disorder.

      • ‘The rare individual who suffers from manic episodes alone also meets criteria for bipolar mood disorder because experience shows that most of these individuals can be expected to become depressed at a later time.’

• Mixed Features:

  • Episodes that involve both depressive and manic symptoms simultaneously.

    • Common dysphoric (anxious or depressive) features during a mixed features manic episodes can be severe.

  • Research shows: Individuals with manic episodes alone are often later expected to experience depressive episodes, qualifying them for a bipolar diagnosis

    • In one study, 30% of patients hospitalized for mania had mixed episodes.

    • In another, two-thirds of bipolar depression episodes also included manic symptoms (e.g., racing thoughts, distractibility, and agitation).

  • DSM-5 “Mixed Features”:

    • Diagnosis requires specifying if a predominantly manic or depressive episode is present with enough symptoms from the opposite polarity to meet criteria for mixed features.

Pattern of Episodes and Treatment Goals for Mood Disorders

• Course of Episodes

  • Important to determine the temporal pattern of episodes:

    • Full Remission: Complete recovery for at least two months between episodes.

    • Partial Remission: Retaining some depressive symptoms.

    • Alternating Episodes: Depressive episodes alternating with manic or hypomanic episodes.

  • Patterning contributes to appropriate diagnosis and treatment decisions.

• Treatment Goals for Mood Disorders

  • Goals include immediate relief from current depressive episodes and prevention of future episodes to prolong well-being.

  • Studies evaluate treatment effectiveness on these long-term preventative goals.

Depressive Disorders Overview

• DSM-5 identifies several types of depressive disorders, differentiated by:

  • Frequency and severity of depressive symptoms

  • Course of symptoms, either chronic (almost continuous or life-long) or non-chronic

• severity and chronicity are the two most important factors in describing mood disorders

Clinical Depressions

• Major Depressive Disorder (also MDD or Clinical Depression) is characterized by persistent feelings of severe depressive symptoms. This disorder occurs in episodes; An episode lasts at least two weeks; If untreated, a typical major depressive episode lasts around 4 to 9 months

  • Most easily recognized and severe mood disorder.

  • Defined by the presence of depressive episodes and the absence of manic or hypomanic episodes throughout the disorder.

• Characteristics of MDD Episode

  • Experiencing a single, isolated depressive episode in a lifetime is relatively rare..

    • Physical Changes: Referred to as "somatic" or "vegetative" symptoms.

      • Changes in sleep, appetite, weight, and energy that make daily activities overwhelming.

    • Cognitive and Emotional

      • Emotional Shutdown: Low behavioral activation.

      • Anhedonia: Reduced ability to experience pleasure, more characteristic than sadness alone.

      • Interest Loss: Reduced interest in previously enjoyable activities, including social interactions and achievements.

      • Feelings of worthlessness and indecisiveness.

• DSM-5 Criteria for Major Depressive Episode

  • Five or more of the following symptoms must occur during the same 2-week period, with at least one symptom being a depressed mood or loss of interest:

    • Persistent depressed mood or irritability (in children/adolescents).

    • Diminished pleasure in activities.

    • Weight change or appetite alteration.

    • Sleep disturbances (insomnia or hypersomnia).

    • Psychomotor agitation or retardation (noticeable by others).

    • Fatigue or loss of energy.

    • Feelings of worthlessness or excessive guilt.

    • Trouble thinking, concentrating, or indecisiveness.

    • Recurrent thoughts of death or suicidal ideation.

  • Symptoms must cause significant impairment in daily functioning and cannot be due to substance use or a medical condition.

• Persistent Depressive Disorder (Dysthymia) is defined by a depressed mood that continues for at least 2 years, during which the patient is not symptom-free for more than 2 months at a time, though they may not experience all symptoms of a major depressive episode

  • Represents individuals previously diagnosed with dysthymic disorder or other depressive disorders (Rhebergen & Graham, 2014)

  • Differs from major depressive disorder:

    • Typically involves fewer symptoms but the depression remains chronic relatively unchanged over long periods—sometimes 20 to 30 years or more

  • Considered more severe due to:

    • Higher comorbidity rates with other mental disorders

    • Lower responsiveness to treatment

    • Slower rate of improvement over time

• Specifiers for Persistent Depressive Disorder

  • Persistent depressive disorder is specified based on the presence or absence of a major depressive episode:

    • With pure dysthymic syndrome: No major depressive episode in at least the preceding two years

    • With persistent major depressive episode: Presence of a major depressive episode over at least a two-year period

    • With intermittent major depressive episodes: Also referred to as double depression, where individuals cycle between major depressive episodes and a baseline persistent depressive state

• Recurrent Major Depressive Disorder

  • If an individual has two or more major depressive episodes separated by at least 2 months without depression, the disorder is noted as recurrent

  • Statistics on recurrence:

    • From 35% to 85% of individuals with a single depressive episode experience a second episode (Angst, 2009; Eaton et al., 2008; Judd, 2000; Souery et al., 2012)

    • The risk of recurrence within the first year following an episode is 20%, rising to 40% by the second year (Boland & Keller, 2009)

  • Median number of lifetime major depressive episodes is 4 to 7; in one large sample, 25% of individuals experienced six or more episodes (Angst, 2009; Kessler & Wang, 2009)

  • Median duration of recurrent major depressive episodes is approximately 4 to 5 months, which is generally shorter than the average length of the first episode (Boland & Keller, 2009; Kessler et al., 2003)

  • Case Example (Katie)

    • Katie experienced a severely depressed mood, feelings of worthlessness, difficulty concentrating, recurrent thoughts of death, sleep difficulties, and loss of energy

    • She met the DSM-5 criteria for major depressive disorder, recurrent

    • Katie’s episodes were severe but tended to cycle in and out

• Double Depression

  • Some individuals experience both major depressive episodes and persistent depression with fewer symptoms

  • Typically, mild depressive symptoms develop first (pure dysthymic syndrome), potentially beginning at an early age, followed later by one or more major depressive episodes

  • Once the major depressive episode resolves, these individuals often revert to the underlying pattern of persistent depression

  • Important to recognize this pattern, as it indicates a more severe psychopathology and a problematic future course

  • In a study, Klein et al. (2006) reported a 71.4% relapse rate in individuals meeting criteria for DSM-IV dysthymia

Other Depressive Disorders

• Introduction of PMDD and DMDD in DSM-5

  • Premenstrual Dysphoric Disorder (PMDD) and Disruptive Mood Dysregulation Disorder (DMDD) were added as depressive disorders.

Premenstrual Dysphoric Disorder (PMDD)

• Diagnostic Criteria for PMDD (DSM-5 Table 7.5)

  • Symptoms must be present in the majority of menstrual cycles.

  • At least five symptoms must occur in the final week before menses, improve within a few days after onset, and become minimal or absent in the week post-menses.

• Required Symptoms (Criterion B)

  • One (or more) of the following must be present:

    • Marked affective lability (e.g., mood swings; sudden sadness or tearfulness).

    • Marked irritability or anger with increased interpersonal conflicts.

    • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.

    • Marked anxiety, tension, or feelings of being keyed up.

• Additional Symptoms (Criterion C)

  • One (or more) must also be present:

    • Decreased interest in usual activities (e.g., work, school, friends).

    • Subjective difficulty in concentration.

    • Lethargy or marked lack of energy.

    • Marked change in appetite, overeating, or specific food cravings.

    • Hypersomnia or insomnia.

    • Sense of being overwhelmed or out of control.

    • Physical symptoms (e.g., breast tenderness, bloating, weight gain).

• Additional Notes

  • Symptoms must be present for most menstrual cycles over the preceding year.

  • Associated with clinically significant distress or interference with functioning (e.g., work, social activities).

  • Disturbance is not merely an exacerbation of another disorder (e.g., major depressive disorder).

  • Diagnosis may be made provisionally prior to confirmation through daily ratings.

  • Symptoms must not be attributable to substance effects or another medical condition.

• History and Controversy of PMDD

  • PMDD was identified as affecting 2% to 5% of women with severe emotional reactions premenstrually (Epperson et al., 2012).

  • Concerns about stigmatization of normal physiological cycles delayed its classification as a disorder.

  • Evidence shows PMDD significantly differs from typical premenstrual symptoms (PMS), which affect 20% to 40% of women without functional impairment (Hartlage et al., 2012).

  • PMDD is best viewed as a mood disorder rather than a physical one, aiding in appropriate treatment for affected women.

Disruptive Mood Dysregulation Disorder (DMDD)

• Disruptive mood dysregulation disorder (DMDD) is a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts. The symptoms of DMDD go beyond a “bad mood.” DMDD symptoms are severe.

• Key Observations

  • Many diagnosed children exhibit chronic irritability without periods of elevated mood, contrary to bipolar disorder criteria (Liebenluft, 2011).

  • Chronic irritability is associated with an increased risk of depression and anxiety disorders rather than mania.

  • Misdiagnosis can lead to inappropriate treatment with powerful medications for bipolar disorder, posing greater risks than benefits

• Misdiagnosis of DMDD

  • Increase in Bipolar Diagnoses in Youth

    • Significant rise in bipolar disorder diagnoses among children from 1995 to 2005, increasing 40-fold (Leibenluft & Rich, 2008; Moreno et al., 2007).

    • Broader diagnostic criteria have led to misdiagnosis of chronic irritability and severe mood regulation issues.

    • To prevent misdiagnosis, DMDD was developed for children up to 12 years exhibiting severe irritability and mood regulation difficulties.

• Diagnostic Criteria for DMDD (DSM-5 Table 7.6)

  • Severe recurrent temper outbursts, either verbally or behaviorally, grossly out of proportion to provocation.

  • Temper outbursts inconsistent with developmental level.

  • Outbursts occurring three or more times weekly.

  • Persistent irritability or anger between outbursts, observable by others.

  • Criteria A-D present for 12 months without a period exceeding three months without symptoms.

  • Symptoms present in at least two settings (home, school, peers).

  • Diagnosis not made before age 6 or after 18.

  • Symptoms must have an onset before age 10.

  • No distinct periods of mania or hypomania.

  • Behaviors do not occur exclusively during major depressive episodes or better explained by another mental disorder.

• Long-term Implications

  • Adults with a history of DMDD are at increased risk for mood and anxiety disorders (Copeland et al., 2014).

  • Future objectives include developing and evaluating effective psychological and pharmacological treatments for DMDD.

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Additional Defining Criteria for Depressive Disorders (DSM-5)

1. Overview

• In DSM-5, clinicians are instructed to specify features, or specifiers, of the latest depressive episode to help determine the most effective treatment or predict the likely course of the disorder.

• Clinicians also rate the episode's severity as mild, moderate, or severe, then use eight core specifiers to further describe depressive disorders, which can apply to both major depressive disorder and persistent depressive disorder. Some specifiers apply only to major depressive disorder.

3. List and Descriptions of Specifiers

• Psychotic Features Specifier

  • During a major depressive or manic episode, some individuals may experience psychotic symptoms, including hallucinations (seeing or hearing things that aren’t there) and delusions (strongly held but inaccurate beliefs).

  • These may include somatic delusions, such as believing the body is rotting internally. Other psychotic symptoms, such as hearing voices calling them evil, are known as mood-congruent hallucinations or delusions because they are consistent with a depressed mood.

  • Less commonly, a person may experience mood-incongruent hallucinations or delusions, such as delusions of grandeur (e.g., believing they possess supernatural abilities), which do not align with a depressed mood.

  • Psychotic symptoms with mood disorders are serious and may signal a depressive episode that could progress to schizophrenia or may already be a symptom of schizophrenia. These conditions occur in about 5%-20% of depressive cases and are associated with poorer responses to treatment, greater impairment, and more persistent symptoms over time.

• Anxious Distress Specifier

  • This specifier highlights the presence and severity of anxiety accompanying a depressive episode, whether meeting the full criteria for an anxiety disorder or involving anxiety symptoms not meeting full criteria.

  • Anxiety associated with mood disorders, now included in DSM-5 as an important specifier, indicates a more severe condition, a higher likelihood of suicidal thoughts, and a poorer treatment outcome.

• Mixed Features Specifier

  • This specifier is applied when a predominantly depressive episode has at least three symptoms of mania.

  • The presence of mixed features in depressive episodes is applicable to both major depressive disorder and persistent depressive disorder.

• Melancholic Features Specifier

  • This applies when the full criteria for a major depressive episode are met, regardless of whether it is within persistent depressive disorder.

  • Melancholic features include severe somatic symptoms such as early-morning awakenings, weight loss, loss of libido (sex drive), excessive or inappropriate guilt, and anhedonia (loss of pleasure in activities).

  • This specifier is typically linked with more severe depressive episodes, though some researchers view it as representing a continuum of depressive severity rather than a unique category.

• Catatonic Features Specifier

  • This serious condition, applicable to depressive and manic episodes, is marked by an absence of movement, or stupor, and catalepsy, where the muscles become waxy and semirigid, causing limbs to stay in a set position.

  • Catatonia can also involve random, excessive movements without purpose. Although previously thought to be more common in schizophrenia, recent research suggests catatonia may appear more often in depression than schizophrenia.

  • This response may be related to feelings of impending doom and is similar to a “freeze” response seen in animals threatened by predators.

• Atypical Features Specifier

  • This applies to depressive episodes, whether in the context of persistent depressive disorder or not, where individuals oversleep and overeat, leading to weight gain and a higher risk of diabetes.

  • While experiencing significant anxiety, people with atypical features may still show pleasure in certain activities, unlike those with more typical depression.

  • This type of depression tends to present more often in women and at a younger age, with higher symptom severity, greater frequency of suicide attempts, and a higher rate of comorbid disorders, such as alcohol abuse.

• Peripartum Onset Specifier

  • This specifier applies to major depressive or manic episodes occurring around childbirth. Approximately 13%-19% of women who give birth meet the criteria for depression, often referred to as peripartum depression.

  • The risk of depression is slightly higher postpartum than during pregnancy, with about 7.2% meeting full criteria for major depressive disorder. Depression in new mothers may lead to serious thoughts of self-harm and, in some cases, harm toward the infant.

  • Fathers are also affected emotionally by childbirth, with about 4% showing an increase in depressive symptoms, and a 10% depression rate for fathers extending from the first trimester to one year after birth.

  • The increased stress and hormonal shifts following childbirth can contribute to this depression, though treatment approaches for peripartum depression are similar to those for other forms of depression.

• Seasonal Pattern Specifier

  • Also known as seasonal affective disorder (SAD), this specifier applies to recurrent major depressive episodes occurring at particular times of year, such as winter.

  • For a seasonal pattern diagnosis, these episodes must have recurred for at least two years without nonseasonal episodes during that period.

  • Most cases involve winter depression, estimated to affect up to 2.7% of North Americans, with symptoms such as oversleeping and increased appetite leading to weight gain.

Seasonal Affective Disorder (SAD): Causes and Treatment

• Biological Mechanisms

  • SAD may be linked to seasonal changes in melatonin, a hormone from the pineal gland. Melatonin production rises in winter with reduced sunlight, potentially triggering depression in sensitive individuals (Goodwin & Jamison, 2007).

  • SAD may also stem from delayed circadian rhythms in winter (“phase shift hypothesis”), causing misalignment with the natural day–night cycle.

• Prevalence

  • SAD is more common in northern and southern latitudes with limited winter sunlight, such as in Fairbanks, Alaska, where 9% meet SAD criteria, and an additional 19% have some symptoms.

  • SAD is consistent over time, with a study showing 86% of patients experienced depressive episodes each winter across 9 years.

  • Prevalence in children and adolescents ranges from 1.7% to 5.5%, with postpubertal girls more affected.

• Treatment

  • Phototherapy: Involves 2 hours of bright morning light, lifting mood within days and achieving remission in weeks. Patients should avoid evening bright light to maximize effectiveness. Side effects include headaches, eyestrain, and feeling “wired” (Levitt et al., 1993).

  • Cognitive-Behavioral Therapy (CBT): Targets negative thoughts and emotional responses. In a study, CBT showed better long-term benefits than light therapy, with fewer relapses and higher remission rates in the second winter (Rohan et al., 2015).

Additional Defining Criteria for Onset and Duration Depressive Disorders (DSM-5)

• Developmental Risk Patterns

  • The risk for developing major depression is low until the early teens.

  • Begins to rise steadily in a linear fashion (Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013).

• Longitudinal Study Findings

  • A study with 2,320 individuals from the Baltimore Longitudinal Study of Aging (ages 19 to 95):

    • Symptoms of depression followed a U-shaped pattern.

    • Highest symptoms in young adults, decreased across middle adulthood, then increased in older age.

    • Older individuals also experience increased distress related to these symptoms (Sutin et al., 2013).

• Incidence of Depression

  • Kessler et al. (2003) found that:

    • 25% of individuals aged 18 to 29 had experienced major depression.

    • This rate was significantly higher than older groups at the same age.

  • Rohde et al. (2013) examined incidence across four age groups:

    • Children (ages 5 to 12): 5% had experienced major depressive disorder.

    • Adolescents (ages 13 to 17): 19%.

    • Emerging adults (ages 18 to 23): 24%.

    • Young adults (ages 24 to 30): 16%.

• Duration of Depressive Episodes

  • Length of depressive episodes varies:

    • Some episodes last as little as 2 weeks.

    • More severe cases may last several years.

    • Typical duration of the first episode is 2 to 9 months if untreated (Angst, 2009; Boland & Keller, 2009; Rohde et al., 2013).

  • Evidence shows that even in severe cases, the probability of remission within 1 year approaches 90% (Kessler & Wang, 2009).

  • For severe cases lasting 5 years or more, 38% are expected to recover (Mueller et al., 1996).

• Residual Symptoms and Recurrence

  • Episodes may leave residual symptoms, increasing the likelihood of subsequent episodes.

  • Treatment planning should consider this increased likelihood (Boland & Keller, 2009; Judd, 2012).

• Prevalence in Children vs. Adults

  • Persistent mild depressive symptoms:

    • Lower prevalence in children (0.07%) compared to adults (3% to 6%) (Klein, Schwartz, Rose, & Leader, 2000).

    • Symptoms tend to be stable throughout childhood (Garber, Gallerani, & Frankel, 2009).

  • Kovacs et al. (1994) found:

    • 76% of children with persistent mild depressive symptoms later developed major depressive disorder.

• Duration of Persistent Depressive Disorder

  • Persistent depressive disorder may last 20 to 30 years or more.

  • Studies report a median duration of approximately 5 years in adults (Klein et al., 2006) and 4 years in children (Kovacs et al., 1994).

  • Klein et al. (2006) found:

    • 74% of adults with DSM-IV dysthymia (now persistent depressive disorder) had recovered at some point, but 71% relapsed.

    • The sample spent approximately 60% of the 10-year follow-up period meeting full criteria for a mood disorder.

    • Compared to 21% of a group with major depressive disorder followed for 10 years.

• Suicide Risk in Persistent Depressive Disorder

  • Patients with persistent depressive disorder (dysthymia) were more likely to attempt suicide than those with nonpersistent episodes of major depressive disorder.

  • Major depressive episodes and dysthymia (persistent depressive disorder) often co-occur (double depression) (Boland & Keller, 2009; McCullough et al., 2000).

  • Up to 79% of individuals with persistent depressive disorder have experienced a major depressive episode.

Understanding Grief in Depression

Transition of Grief to Depression

• Initial Reactions to Loss

  • Grief may present depressive symptoms, anxiety, emotional numbness, and denial following the death of a loved one (Shear, 2012; Shear et al., 2011; Simon, 2012).

  • Severe symptoms may require immediate treatment, potentially resulting in a major depressive episode with psychotic features, suicidal ideation, or severe functional impairment (Maciejewski et al., 2007).

• Cultural Context of Grieving

  • Cultures have rituals (e.g., funerals, burial ceremonies) to support emotional processing of loss (Bonanno & Kaltman, 2001; Gupta & Bonanno, 2011; Shear, 2012).

  • The natural grieving process typically peaks within the first 6 months, though it can last a year or longer (Currier, Neimeyer, & Berman, 2008; Maciejewski et al., 2007).

• Evolution of Grief

  • Acute grief evolves into integrated grief, which means acknowledging the finality of death and adjusting to the loss.

  • Positive memories of the deceased become more prominent, with less interference in daily functioning (Shear et al., 2011).

• Recurrence of Grief Symptoms

  • Integrated grief can recur at significant anniversaries (e.g., birthdays, holidays, anniversary of death).

  • Grieving is a normal process; concern arises when it persists beyond typical timeframes (Neimeyer & Currier, 2009).

• Transition to Complicated Grief

  • After 6 months to a year, the chance of recovering from severe grief without treatment significantly decreases.

  • Approximately 7% of bereaved individuals may develop a disorder (Kersting et al., 2011; Shear et al., 2011).

  • Increased suicidal thoughts may emerge, often focused on reuniting with the deceased (Stroebe, Stroebe, & Abakoumkin, 2005).

  • Impaired future thinking and rigid emotional regulation are common (MacCallum & Bryant, 2011; Robinaugh & McNally, 2013).

• Complicated Grief in Children and Young Adults

  • Sudden loss of a parent makes children particularly vulnerable to prolonged depression (Brent et al., 2009; Melhem et al., 2011).

• Diagnostic Considerations for Complicated Grief

  • Some propose complicated grief as a distinct diagnostic category due to its unique symptom cluster (Bonanno, 2006; Shear et al., 2011).

  • Complicated grief symptoms include intense yearning and activation of the dopamine neurotransmitter system, contrasting with major depressive disorder (O’Connor et al., 2008).

• Diagnostic Category in DSM-5

  • Persistent Complex Bereavement Disorder is included as a diagnosis requiring further study in section III of DSM-5.

Symptoms of Acute Grief

• Normal Limits: 6-12 Months Post-Loss

• Recurrent strong feelings of yearning and desire to reunite with the deceased.

• Pangs of deep sadness, remorse, and episodes of crying, interspersed with positive emotions.

• Frequent thoughts or vivid images of the deceased, including possible hallucinatory experiences.

• Difficulty accepting the reality of death, accompanied by bitterness or anger.

• Somatic distress: uncontrollable sighing, digestive issues, loss of appetite, fatigue, sleep disturbances, etc.

• Feelings of disconnection from the world and irritability with others.

Symptoms of Integrated Grief (Normal Limits)

• Sense of adjustment to the loss.

• Restoration of interest, sense of purpose, and capacity for joy.

• Emotional loneliness may persist.

• Background feelings of sadness and longing.

• Thoughts and memories of the deceased are bittersweet, no longer dominating the mind.

• Occasional hallucinatory experiences of the deceased.

• Surges of grief may occur on significant anniversaries.

Symptoms of Complicated Grief

• Persistent intense symptoms of acute grief.

• Excessive or distracting concerns about the death's circumstances or consequences.

• Therapeutic Approach for Complicated Grief

  • Encourages reexperiencing the trauma while discussing the deceased, the death, and its meaning (Shear et al., 2014).

  • Integration of positive memories with negative emotions to achieve a state of integrated grief (Currier et al., 2008).

  • Studies show this approach is more successful than alternative psychological treatments (Bryant et al., 2014; Shear et al., 2014; Simon, 2013).

Bipolar Disorders

• Bipolar Disorders (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in a person’s mood, energy, activity levels, and concentration. These shifts can make it difficult to carry out day-to-day tasks.

  • These moods range from periods of extremely “up,” elated, irritable, or energized behavior (known as manic episodes) to very “down,” sad, indifferent, or hopeless periods (known as depressive episodes).

• Key Feature

  • Bipolar disorders are characterized by manic episodes alternating with major depressive episodes, creating a cycle of elation and despair.

• Signs and Symptoms:

  • Symptoms. People with bipolar disorder experience periods of unusually intense emotion and changes in sleep patterns and activity levels, and engage in behaviors that are out of character for them—often without recognizing their likely harmful or undesirable effects. These distinct periods are called mood episodes. Mood episodes are very different from the person’s usual moods and behaviors. During an episode, the symptoms last every day for most of the day. Episodes may also last for longer periods, such as several days or weeks.

• Manic Episodes

  • Manic episodes may occur once or repeatedly.

• There are three types of bipolar disorder:

  • Bipolar I

  • Bipolar II

  • Cyclothymic

• Bipolar I disorder is defined by manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depressive symptoms and manic symptoms at the same time) are also possible. Experiencing four or more episodes of mania or depression within 1 year is called “rapid cycling.”

• Bipolar II disorder is defined by a pattern of depressive episodes and hypomanic episodes. The hypomanic episodes are less severe than the manic episodes in bipolar I disorder.

• Cyclothymic disorder (also called cyclothymia) is defined by recurring hypomanic and depressive symptoms that are not intense enough or do not last long enough to qualify as hypomanic or depressive episodes.

DSM-5 Diagnostic Criteria for Bipolar II Disorder

• Criteria:

  • At least one hypomanic episode and one major depressive episode.

• Differences from Manic Episodes:

  • Hypomanic episode minimum duration: 4 days.

  • Change in functioning not severe enough for marked impairment or hospitalization.

  • No psychotic features present.

• Exclusion Criteria:

  • No history of manic episodes.

  • Symptoms not better explained by other psychotic disorders.

• Impact on Functioning:

  • Symptoms cause clinically significant distress or impairment in functioning.

• Specify Current or Most Recent Episode:

  • Hypomanic or Depressed.

• Specify If:

  • With anxious distress.

  • With mixed features.

  • With rapid cycling.

  • With mood-congruent or mood-incongruent psychotic features.

  • With catatonia.

  • With peripartum onset.

  • With seasonal pattern.

• Specify Course:

  • In full or partial remission.

• Specify Severity:

  • Mild, moderate, or severe if full criteria for a mood episode are currently met.

Bipolar Disorder: Additional Overview of Specifiers:

Specifiers for depressive disorders also apply to bipolar disorders (refer to DSM-5 Table 7.5).

• Key Specifiers:

  • Catatonic Features:

    • Primarily associated with major depressive episodes, rarely applies to manic episodes.

  • Psychotic Features:

    • May occur during manic episodes, often with delusions of grandeur.

  • Anxious Distress:

    • Present in both bipolar and depressive disorders.

  • Mixed Features:

    • New in DSM-5; describes major depressive or manic episodes with symptoms from the opposite polarity (e.g., a depressive episode with some manic symptoms).

  • Seasonal Pattern:

    • Individuals may experience depression in winter and mania in summer.

  • Peripartum Period:

    • Manic episodes may occur around childbirth.

• Assessment of Past Episodes:

  • Determine if the patient has experienced episodes of major depression or mania previously.

  • Establish whether the individual fully recovered between past episodes.

  • Assess if cyclothymia preceded the onset of bipolar disorder, as its presence indicates a decreased chance for full inter-episode recovery (Akiskal, 2009).

Onset and Duration of Bipolar Disorders

• Average Age of Onset:

  • Bipolar I disorder: 15 to 18 years.

  • Bipolar II disorder: 19 to 22 years, with childhood cases also present (Angst, 2009).

• Development:

  • Bipolar disorders develop more acutely than major depressive disorder, often preceded by minor mood oscillations (Goodwin & Jamison, 2007).

• Progression:

  • 10% to 25% of individuals with bipolar II disorder may progress to bipolar I disorder (Birmaher et al., 2009).

• Overlap with Unipolar Depression:

  • Older studies suggest 25% of depressed individuals may later experience manic episodes (Angst & Sellaro, 2000).

  • As many as 67.5% of unipolar depression patients may experience manic symptoms, indicating a possible spectrum between unipolar depression and bipolar disorder (Johnson et al., 2009).

• Age and Course:

  • Rare for bipolar disorder to develop after age 40; once onset occurs, the course is chronic with alternating mania and depression.

• Management:

  • Therapy focuses on ongoing drug regimens to prevent recurrence of episodes.

• Suicide Risk:

  • High risk associated with bipolar disorder, particularly during depressive episodes (Angst, 2009).

  • Studies indicate a shorter lifespan for those with bipolar disorder due to medical diseases and suicide, although early treatment can mitigate this risk (Crump et al., 2013).

DSM-5 Diagnostic Criteria for Cyclothymic Disorder

• Definition: A chronic, milder version of bipolar disorder characterized by alternating mood elevation and depression without reaching full manic or major depressive severity.

• Duration:

  • At least 2 years (1 year in children and adolescents) of numerous periods with:

    • Hypomanic symptoms not meeting criteria for a hypomanic episode.

    • Depressive symptoms not meeting criteria for a major depressive episode.

• Presence of Symptoms:

  • During the 2-year period, symptoms must be present for at least half the time, with no more than 2 months symptom-free.

  • Individuals experience mild depressive symptoms and hypomanic episodes but do not require hospitalization.

• Exclusion Criteria:

  • Criteria for major depressive, manic, or hypomanic episodes have never been met.

  • Symptoms not better explained by other psychotic disorders.

  • Symptoms not attributable to substance effects or another medical condition.

• Impact on Functioning:

  • Although often seen as just moody, the mood fluctuations interfere with functioning and increase the risk of developing bipolar I or II disorder.

• Specify if:

  • With anxious distress.

• Nature:

  • Chronic: Typically lifelong; 30-50% of patients may develop full-blown bipolar disorder (Kochman et al., 2005).

• Demographics:

  • 60% of cyclothymic patients are female, with onset often in teenage years (Goodwin & Jamison, 2007).

• Recognition Issues:

  • Often unrecognized; patients may be viewed as high-strung or moody.

• Subtypes:

  • Subtypes may focus on predominance of depressive or hypomanic symptoms, or an equal distribution of both.

Rapid-Cycling (Unique Specifier)

• Definition:

  • Unique to bipolar I and II disorders; characterized by rapid transitions between depressive or manic episodes.

• Criteria:

  • At least four manic or depressive episodes within a year.

• Impact on Severity:

  • Associated with severe bipolar disorder that may not respond well to standard treatments (Angst, 2009; Kupka et al., 2005).

  • Higher probability of suicide attempts and more severe episodes (Coryell et al., 2003).

  • Alternative drug treatments, such as anticonvulsants and mood stabilizers, may be more effective than antidepressants for this group (Kilzieh & Akiskal, 1999).

• Prevalence:

  • Approximately 20% to 50% of bipolar patients experience rapid cycling; 60% to 90% are female (Altshuler et al., 2010; Coryell et al., 2003).

• Course of Rapid Cycling:

  • Tends to increase in frequency over time, potentially leading to treatment-resistant forms.

  • Not typically permanent; 80% return to a non-rapid-cycling pattern within 2 years (Coryell et al., 2003).

  • Ultra-rapid and ultra-ultra-rapid cycling observed, linked to circadian factors (Wilk & Hegerl, 2010).

EXAMPLES of diagnosing Bipolar

• Case Study: Jane

  • Background: Nearly 50, married to a surgeon, and mother of three.

  • Family Situation: Youngest son, 16-year-old Mike, struggling academically and anxious; Jane brings him to the clinic.

  • Observation:

    • Jane appears well-dressed, vivacious, and energetic, discussing her family’s achievements enthusiastically.

    • Mike, in contrast, is quiet, masking distress.

  • Mental State:

    • Jane is in a hypomanic episode, showing enthusiasm, grandiosity, rapid speech, and minimal sleep.

    • She admits to being “manic depressive” and has medication for her condition.

  • Impact on Family:

    • Mike is treated for obsessive-compulsive disorder (OCD) but shows little progress.

    • Life at home is difficult during Jane’s depressive episodes, which last about 3 weeks and leave her immobilized.

    • Children must care for themselves and Jane during her depressive stupor.

  • Mood Cycle:

    • After depressive episodes, Jane transitions into hypomanic episodes lasting months, during which she is entertaining and engaging.

  • Diagnosis:

    • Jane suffers from bipolar II disorder (major depressive episodes alternate with hypomanic episodes).

    • Bipolar I disorder involves full manic episodes, whereas bipolar II features hypomanic episodes.

• Case Study: Billy

  • Initial Encounter: Billy admitted to the hospital; his exuberance is evident as he expresses enthusiasm for Ping-Pong.

  • Behavior During Manic Episode:

    • Recently, he impulsively spent money on stereo equipment to create a sound studio.

    • Denies having a problem despite poor financial decisions.

  • Challenges:

    • Individuals in manic phases may cease medication to re-experience the high of mania, complicating treatment.

• Treatment and Outcomes

  • Jane’s son Mike shows improvement after working at a ski and tennis resort, suggesting that his issues may be linked to Jane’s condition.

  • Tragically, Jane later dies by suicide during a depressive episode.

Prevalence of Mood Disorders

• Epidemiological Studies:

  • Recent studies estimate approximately 16% of the global population experiences major depressive disorder (MDD) over their lifetime.

  • About 6% have experienced MDD in the past year.

• Persistent Depressive Disorder:

  • Rates for persistent depressive disorder (dysthymia) and chronic major depression are around 3.5% for both lifetime and past-year prevalence.

• Bipolar Disorder:

  • The lifetime prevalence for bipolar disorder is about 1%, with a past-year prevalence of 0.8%.

  • Both persistent depressive disorder and bipolar disorders are chronic, lasting much of an individual's life.

• Gender Differences:

  • Women are twice as likely as men to have mood disorders, primarily due to major depressive disorder and persistent depressive disorder.

  • Bipolar disorders are distributed equally among genders, though women may experience more rapid cycling and anxiety and tend to be in a depressive rather than manic phase.

• Racial Prevalence:

  • Major depressive disorder and persistent depressive disorder rates are significantly lower among Black individuals compared to White individuals, while bipolar disorder rates show no significant differences.

  • In African American communities, the prevalence of major depressive disorder in a community sample was found to be around 3.1% to 4.52% in the past year.

  • Fair or poor health is a major predictor of depression in African Americans, with only 11% receiving appropriate treatment.

  • Native Americans exhibit a significantly higher prevalence of depression, but cultural differences in understanding depression complicate this finding.

Prevalence in Children, Adolescents, and Older Adults

• Children and Adolescents:

  • Estimates indicate depressive disorders are less common in prepubertal children but rise dramatically during adolescence.

  • Rates of major depression in children ages 2 to 5 are about 1.5% and decrease slightly in later childhood.

  • Between 20% to 50% of children may experience some depressive symptoms that do not meet diagnostic criteria but still cause impairment.

  • Adolescents experience major depressive disorder as frequently as adults.

  • The sex ratio for depressive disorders in children is approximately 50:50, shifting dramatically in adolescence, where major depressive disorder becomes predominantly female.

• Older Adults:

  • The prevalence of major depressive disorder in individuals over 65 is about half that of the general population, possibly due to a decrease in stressful life events.

  • Milder depressive symptoms that do not meet criteria for major depressive disorder are more common in the elderly and often related to illness and infirmity.

  • Bipolar disorder rates in children and adolescents are comparable to those in adults.

  • Diagnosis of bipolar disorder has increased due to broader diagnostic criteria in children.

Life Span Developmental Influences on Mood Disorders

• Mood Disorder Characteristics:

  • The characteristics of mood disorders vary with age; depressive behaviors can manifest even in infants of depressed mothers.

  • No mood disorders specific to childhood exist in DSM-5, except for disruptive mood dysregulation disorder, applicable only to individuals up to 12 years of age.

  • Depressive symptoms in young children might include sad expressions, irritability, fatigue, and sleep or eating problems.

  • Preschool depression can predict later depression and other disorders.

• Mania in Children:

  • Children under 9 may show more irritability and emotional swings compared to classic manic states seen in adults.

  • Emotional swings in children may appear as less distinct manic episodes.

• Comorbidity Patterns:

  • Childhood depression often co-occurs with ADHD or conduct disorder, with the latter involving aggression and destructive behavior.

  • Successful treatment of depression may alleviate associated ADHD or conduct disorder.

• Long-Term Consequences:

  • Adolescents with major depressive disorder face a higher risk for later mental health issues, substance abuse, and educational challenges.

  • Early intervention is crucial; cognitive-behavioral therapy (CBT) can effectively prevent depressive episodes in at-risk youth.

Age-Based Influences on Older Adults

• Depression in the Elderly:

  • Depression among the elderly has only been recognized recently, with a significant percentage of nursing home residents likely experiencing major depressive episodes.

  • Many elderly patients do not remit from depression, cycling in and out of depressive states.

  • Late-onset depression is often associated with sleep difficulties, illness anxiety, and agitation.

• Challenges in Diagnosis:

  • Diagnosing depression in older adults is complicated as physical illness or dementia can mask depressive symptoms.

  • High comorbidity with anxiety disorders and alcohol abuse is common in elderly patients.

• Influence of Life Events:

  • Events like entering menopause, loss of independence, or death of a spouse are strong risk factors for depression in older adults.

  • Increased frailty and social isolation are linked to higher rates of depression, creating a vicious cycle.

• Suicide Rates:

  • Older adults have higher suicide rates than other age groups, although rates have decreased recently.

  • Optimism can prevent depression and improve longevity in elderly patients.

• Gender Imbalance:

  • The gender imbalance in depression diminishes after age 65, with increased rates of depression in men as they age.

Across Cultures

• Somatic Symptoms:

  • Many cultures express mood disorders through physical symptoms rather than emotional language, such as reporting stomachaches or fatigue.

  • Idioms for depression vary; some cultures might describe it in terms of spiritual distress.

• Cultural Perceptions:

  • Cultural views on individuality versus collectivism influence how depression is perceived and expressed.

• Prevalence Variations:

  • Specific communities, such as Native American villages, show significantly higher rates of mood disorders, often due to chronic life stressors.

Among Creative Individuals

• Historical Observations:

  • Notable figures in history have linked creativity to mood disorders, particularly manic states.

  • Many famous poets have exhibited signs of bipolar disorder, with some having committed suicide.

• Research Findings:

  • Studies indicate that creativity is associated with manic episodes rather than depressive states.

  • Genetic vulnerabilities to mood disorders may also correlate with creativity.

• Implications:

  • Understanding the relationship between mood disorders and creativity may enhance insights into both psychological health and artistic expression.

Causes of Mood Disorders (An Overview)

• Equifinality: Different causes can lead to similar outcomes, such as various reasons for depression.

• Integration of Factors: Mood disorders are influenced by biological, psychological, and social dimensions, highlighting the strong relationship between anxiety and depression.

Biological Dimensions

Familial and Genetic Influences

Research Complexity: Investigating genetic contributions to mood disorders involves challenging methodologies like family and twin studies.

• Family Studies:

  • Prevalence of mood disorders in first-degree relatives (probands) shows a 2-3 times higher rate compared to controls without mood disorders.

  • Higher rates are associated with:

    • Increased severity and recurrence of major depression.

    • Earlier age of onset in the proband.

• Twin Studies:

  • Comparing identical twins (100% genetic similarity) with fraternal twins (50% genetic similarity) reveals higher rates of mood disorders in identical twins.

  • Heritability estimates:

    • 66.7% for bipolar disorder in identical twins vs. 18.9% in fraternal twins.

    • 45.6% for unipolar disorder vs. 20.2%.

• Meta-analysis Findings:

  • Estimated heritability of depression is approximately 37%.

  • Shared environmental factors have minimal influence; 63% variance attributed to non-shared environmental factors.

• Sex Differences:

  • Studies indicate higher heritability in women (36%-44%) vs. men (18%-24%).

• Bipolar Disorder:

  • Confers an increased risk for developing other mood disorders, supporting the notion of bipolar disorder as a severe variant rather than a distinct disorder.

  • If one identical twin has unipolar disorder, the likelihood of the other twin having bipolar disorder is low.

• Genetic Contributions:

  • Similar genetic factors for depression in bipolar and unipolar disorders, but distinct genetics for mania.

  • Overwhelming evidence suggests familial patterns in mood disorders and a genetic vulnerability, particularly in women.

  • Variability in genetic patterns contributes to different types of depression.

• Overall Estimates:

  • Genetic contributions to depression are around 40% for women and 20% for men; higher for bipolar disorder.

  • Environmental factors account for 60%-80% of the causes of depression.

Biological Interaction with Psychological and Social Factors

• Unique Non-Shared Events:

  • Nonshared environmental experiences interact with biological vulnerabilities to cause depression.

Mood Disorders paired with Anxiety

• Relatedness:

  • Evidence shows a close relationship among anxiety, depression, and panic disorders, suggesting a common genetic predisposition.

  • Psychological and social factors differentiate anxiety from depression rather than genetic factors.

Neurotransmitter Systems

• Complex Interactions:

  • Low serotonin levels are implicated in mood disorders, especially in conjunction with norepinephrine and dopamine.

  • The "permissive" hypothesis suggests that low serotonin allows other neurotransmitters to become dysregulated, leading to mood irregularities.

• Dopamine's Role:

  • Interest in dopamine, especially regarding manic episodes and depression, highlights its complex relationship with mood disorders.

Endocrine System

• Stress Hypothesis:

  • Focus on HPA axis overactivity leading to excessive cortisol production linked to depression and anxiety.

  • Dexamethasone suppression test (DST) showed reduced suppression in depressed patients, indicating potential biological markers for depression.

• Consequences of Elevated Stress Hormones:

  • Long-term overproduction of stress hormones can harm neurons and inhibit neurogenesis, particularly in the hippocampus.

Sleep and Circadian Rhythms

• Sleep Disturbances:

  • Depressed individuals show shorter sleep onset to REM sleep and increased REM activity, with alterations in deep sleep stages.

  • Sleep issues may precede or contribute to depression onset and can be more severe in older adults.

• Treatment Implications:

  • Treating insomnia may enhance depression treatment outcomes.

  • Sleep deprivation can lead to temporary mood improvements.

Brain Structure and Function

• EEG Studies:

  • EEG Studies:

    • Depressed individuals exhibit greater right-sided anterior brain activation, potentially indicating vulnerability to depression.

    • Right-sided activation could be a predisposition to depression.

  • Comparative Studies:

    • Bipolar patients may show opposite patterns of brain activity, indicating different underlying mechanisms.

  • Brain Regions:

    • Prefrontal cortex, hippocampus, anterior cingulate cortex, and amygdala show varying activity in depression.

  • Additional Brain Regions:

    • Ongoing studies focus on the anterior cingulate cortex and amygdala for insights into depression-related brain function and activity.

Summary

• Understanding mood disorders involves a multifaceted approach that includes genetic, neurobiological, and psychosocial factors.

• This research aims to elucidate the complex interactions that contribute to mood disorders and their symptoms.

Psychological Dimensions

• Overview of Factors

  • Genetic and biological factors contribute to mood disorders.

  • Psychological and social dimensions also play a significant role.

• Stressful Life Events

  • Stress and trauma are critical contributors to psychological disorders.

  • Diathesis-stress model explains the interaction of genetic and psychological vulnerabilities with stressful life events.

• Impact of Stress on Depression

  • Most individuals with depression report major life changes (e.g., job loss, divorce, childbirth).

  • Researchers now focus on the context and meaning of events rather than just the events themselves.

  • Example of job loss:

    • Context changes the significance of the event (e.g., financial stability vs. living paycheck to paycheck).

    • Reactions vary: one may feel like a failure, while another might see it as an opportunity.

  • Studying life events is complex; methodology continues to evolve.

• Research Findings on Stress and Depression

  • Stressful life events correlate strongly with the onset of mood disorders.

  • Studies indicate a link between severe life events (e.g., childhood sexual abuse) and the first onset of depression.

  • For those with recurrent depression, severe stress before episodes predicts poorer treatment response and higher recurrence likelihood.

• Specific Stressful Events

  • Relationship breakups are notably impactful for both adolescents and adults.

  • Twin studies show that experiencing loss increases the likelihood of depression significantly, especially when humiliation is involved.

• Reciprocal Model of Stress and Depression

  • Gene-environment correlation model suggests genetics can predispose individuals to stress-inducing situations.

  • Stress triggers depression, while depression may lead individuals to seek out stressful environments.

  • Adolescents often attribute their depression to stressors, while mothers may see it as a result of the adolescent's behavior.

  • Genetic influences may be more significant in childhood, while environmental effects gain importance with age.

• Stress and Bipolar Disorder

  • Stressful events significantly affect bipolar disorder episodes.

  • Negative life events typically trigger depression; however, positive stressful events can trigger mania (e.g., achieving significant goals).

  • As bipolar disorder progresses, episodes may become self-sustaining.

  • Sleep disturbances (e.g., postpartum or jet lag) can also trigger manic episodes.

• Vulnerability to Mood Disorders

  • A significant percentage (20% to 50%) of individuals experiencing severe stress develop mood disorders, indicating many do not.

  • Interaction of stressful life events with genetic, psychological, or combined vulnerabilities is crucial.

• Learned Helplessness

  • Stressful life events can lead to feelings of helplessness, contributing to depression.

  • Case Study: Katie’s transition to junior high leads to anxiety and feelings of loss of control.

    • Learned helplessness theory suggests individuals may feel anxious and depressed when they perceive no control over their stress.

• Cognitive Styles and Depression

  • Cognitive errors and schemas lead to a negative view of self, world, and future (depressive cognitive triad).

  • Negative attributional styles (internal, stable, global) contribute to feelings of helplessness.

  • Longitudinal studies suggest negative cognitive styles can develop from early stressful experiences.

• Cognitive Vulnerability

  • Negative cognitive styles can predict depression, supported by studies showing high-risk individuals are significantly more likely to experience depressive episodes.

  • Contagion of cognitive vulnerability may occur; living with vulnerable individuals can lead to similar styles and increased depressive symptoms.

Social and Cultural Dimensions

Overview

• Various social and cultural factors contribute to the onset or maintenance of depression, with key influences being marital relationships, gender, and social support.

Marital Relations

• Interpersonal Stress and Mood Disorders

  • Depression and bipolar disorder are significantly influenced by interpersonal stress, particularly marital dissatisfaction.

  • Disruptions in relationships can often lead to depression.

• Study Findings

  • In a study of 695 women and 530 men re-interviewed over a year, approximately:

    • 21% of women who experienced a marital split developed severe depression, three times higher than those in stable marriages.

    • 17% of men who separated reported severe depression, nine times higher than their married counterparts.

    • Among participants with no prior history of severe depression, 14% of separating men and 5% of separating women experienced severe depression.

  • Men face a higher immediate risk of developing a mood disorder post-marital split.

• Impact of Depression on Marital Relationships

  • Ongoing depression, particularly in bipolar disorder, can deteriorate marital relationships.

  • Being around a negatively affected partner can lead to increased stress and potential arguments, which may push the non-depressed spouse to leave.

• Gender Differences in Marital Conflict

  • Men typically withdraw or disrupt the relationship due to depression, while for women, relationship problems tend to induce depressive symptoms.

  • Therapists are encouraged to address both mood disorders and marital issues simultaneously to enhance treatment outcomes.

• Bipolar Disorder and Marriage

  • Individuals with bipolar disorder are less likely to marry and more likely to divorce, but those who remain married may have better outcomes due to spousal support in treatment.

Mood Disorders in Women

• Prevalence and Gender Disparities

  • Women account for nearly 70% of individuals with major depressive disorder and persistent depressive disorder (dysthymia).

  • Gender ratios remain consistent globally, though overall rates of mood disorders may differ across countries.

• Influence of Gender Roles

  • Gender differences in emotional disorders may stem from perceptions of uncontrollability.

  • Cultural expectations often dictate that men be independent and assertive, while women are viewed as passive and reliant on others. This dependence can increase women’s vulnerability to emotional disorders.

• Parenting Styles and Early Vulnerability

  • Parenting that enforces stereotypical gender roles may contribute to early psychological vulnerability, with overprotective styles hindering initiative.

  • A notable increase in depression among girls during puberty may also be linked to these cultural factors, as well as early physical maturation leading to distress.

• Value of Relationships and Coping Mechanisms

  • Women often place greater value on intimate relationships, making them more susceptible to depression from relational disruptions.

  • A larger and more supportive social network can protect women from depression, but disruptions, such as divorce, can significantly increase their risk.

• Ruminative vs. Activating Coping Styles

  • Women may engage in rumination and self-blame during depressive episodes, which can lead to a higher likelihood of developing depression under stress.

  • Men may cope by engaging in activities, which can be therapeutic and promote recovery.

• Social Disadvantages Faced by Women

  • Women experience higher rates of discrimination, poverty, and abuse, contributing to higher levels of depression compared to men.

  • Single, divorced, and widowed women experience more depression than men in similar circumstances.

• Gender Differences in Other Disorders

  • Disorders associated with aggression and substance abuse are more prevalent in men, suggesting that gender role stereotypes may also influence these patterns.

Social Support

• Influence of Social Factors on Depression

  • Social influences significantly affect psychological functioning and can increase vulnerability to depression.

  • People living alone are nearly 80% more likely to experience depression compared to those living with others.

• Importance of Supportive Relationships

  • Brown and Harris (1978) found that only 10% of women with a close friend to confide in developed depression after serious life stress, compared to 37% without such support.

  • Subsequent studies confirmed that social support plays a crucial role in preventing and recovering from depressive symptoms globally.

• Unique Effects of Social Support in Bipolar Disorder

  • Social support aids recovery from depressive episodes in bipolar disorder but does not have the same effect on manic episodes.

• Interpersonal Psychotherapy

  • The findings on social support have led to the development of interpersonal psychotherapy as an effective treatment for emotional disorders.

• Katie’s Reflection on Support

  • Katie highlighted her parents' strength and commitment despite lacking social support, illustrating the significance of familial support in navigating difficult times

Summary of Causes of Mood Disorders: An Integrative Theory

How do we put all this together?

• Common Biological Vulnerability

  • Depression and anxiety share a common, genetically determined biological vulnerability defined as an overactive neurobiological response to stress.

  • A genetic pattern implicated in this vulnerability is the serotonin transporter gene-linked polymorphic region.

  • This vulnerability indicates a general tendency to develop mood disorders rather than a specific predisposition to either depression or anxiety.

• Psychological Vulnerabilities

  • Individuals who develop mood disorders tend to experience psychological vulnerabilities characterized by feelings of inadequacy in coping with challenges and exhibiting depressive cognitive styles.

  • This sense of control is formed in childhood and ranges from total confidence to complete inability to cope.

  • The “giving up” process, marked by pessimism, plays a crucial role in the development of depression when vulnerabilities are triggered.

• Neuroticism and Negative Affect

  • The combination of inadequate coping mechanisms and depressive cognitive styles contributes to the temperament of neuroticism or negative affect.

  • Neuroticism is associated with biochemical markers of stress and depression, and it reflects differential levels of arousal in the brain's hemispheres.

  • There is strong evidence supporting the connection between genetic vulnerabilities and generalized psychological vulnerabilities.

• Impact of Stressful Life Events

  • Stressful life events are significant triggers for the onset of depression, particularly initial episodes, among vulnerable individuals.

  • These events activate stress hormones that have extensive effects on neurotransmitter systems, particularly serotonin, norepinephrine, and the corticotropin-releasing factor system.

• Research Example: Acute Tryptophan Depletion (ATD)

  • The study by Booij and Van der Does involved 39 patients who had recovered from major depression, participating in ATD challenges that temporarily lowered serotonin levels through dietary changes.

  • Findings revealed that depressive symptoms were more pronounced in individuals who exhibited cognitive vulnerability before the biological challenge, suggesting that cognitive vulnerability is a predictor of depressive responses.

  • Healthy individuals did not experience significant mood changes during ATD, reinforcing the importance of individual vulnerabilities.

• Diathesis-Stress Model Mechanism

  • This research illustrates a potential mechanism for the diathesis-stress model, highlighting the interaction between biological and psychological factors in the development of mood disorders.

• Protective Factors

  • Factors such as interpersonal relationships and cognitive styles may protect individuals from stress's effects and influence recovery from mood disorders.

  • Conversely, individuals with bipolar disorder appear to have different genetic underpinnings and responses to social support, showing heightened sensitivity to life events linked to pursuing goals.

• Bipolar Disorder Specifics

  • The unique sensitivities of individuals with bipolar disorder are hypothesized to stem from an overactive behavioral approach system (BAS), which may make them more responsive to stressful life events, including those that are positive but stressful (e.g., starting a new job).

  • Such events can trigger manic episodes in vulnerable individuals rather than depressive episodes.

  • Individuals with bipolar disorder are also sensitive to disruptions in circadian rhythms, suggesting potential predispositions to both depressive and manic states.

• Summary of Influencing Factors

  • The development of mood disorders involves a complex interplay of biological, psychological, and social factors.

  • While this integrative model offers valuable insights, it does not entirely account for all variations of mood disorders, such as seasonal patterns and bipolar presentations, which are associated with distinct genetic contributions and specific triggering life events.

  • Understanding why someone with a genetic vulnerability may develop a mood disorder rather than anxiety or somatic symptom disorders involves considering specific psychosocial circumstances and early learning experiences that interact with genetic vulnerabilities and personality traits.

Treatment of Mood Disorders (An Overview)

• Understanding Neurobiology of Mood Disorders

  • Recent research has greatly enhanced the understanding of the neurobiology of mood disorders.

  • Studies focus on the complex interplay of neurochemicals, providing insights into the nature of these disorders.

• Role of Medications

  • The primary effect of medications for mood disorders is to alter levels of neurotransmitters and related neurochemicals.

  • These medications can help manage symptoms by addressing chemical imbalances in the brain.

• Other Biological Treatments

  • Electroconvulsive therapy (ECT) is another treatment option that significantly affects brain chemistry.

• Impact of Psychological Treatments

  • Powerful psychological treatments have also been shown to alter brain chemistry, highlighting the importance of therapy alongside medication.

• Trends in Treatment Over Time

  • There was a substantial increase in the rate of outpatient treatment for depression in the U.S. from 1987 to 2007.

    • Approximately 75% of all patients treated during this period received antidepressant drugs.

    • Interestingly, the percentage of individuals receiving psychotherapy actually declined during this time.

• Challenges in Treatment Accessibility

  • Despite advancements in treatment, a significant number of depression cases remain untreated.

  • This lack of treatment is often due to:

    • Failure of healthcare professionals and patients to recognize or properly diagnose depression.

    • Lack of awareness regarding the effective and successful treatments available.

• Importance of Awareness

  • Understanding and learning about the available treatments for depression is crucial for improving patient outcomes and reducing untreated cases.

Medications

Overview of Anti-depressant Medications

• Effectiveness: A number of medications are effective treatments for depression. Approximately 50% of patients experience some benefit, with about half of this group nearing normal functioning (remission).

• Dropout Impact: If dropouts are excluded, the percentage of patients receiving at least some benefit increases to 60% to 70%. However, a meta-analysis suggests that antidepressants are relatively ineffective for mild to moderate depression compared with placebo, showing a clear advantage only for severely depressed patients.

Types of Anti-depressants

1. Selective-Serotonin Reuptake Inhibitors (SSRIs)

   • Mechanism: Block presynaptic reuptake of serotonin, temporarily increasing levels at receptor sites. The long-term mechanism is unknown.

   • Example: Fluoxetine (Prozac) is the most well-known SSRI. Initially viewed as a breakthrough, it later faced scrutiny for potential risks of suicidal thoughts and reactions. However, research indicates that the risk of suicide is not greater than with other antidepressants.

   • Adolescent Concerns: Increased thoughts about suicide may occur in adolescents during initial weeks of treatment, but SSRIs may prevent depression from leading to suicide in the long term.

   • Side Effects: Common side effects include physical agitation, sexual dysfunction (affecting 50% to 75% of users), low sexual desire, insomnia, and gastrointestinal upset.

2. Mixed Reuptake Inhibitors

   • Example: Venlafaxine (Effexor) is a well-known mixed reuptake inhibitor that blocks the reuptake of norepinephrine in addition to serotonin. It has fewer cardiovascular risks compared to other classes, but still presents typical side effects like nausea and sexual dysfunction.

3. Monoamine Oxidase (MAO) Inhibitors

   • Mechanism: Block the enzyme monoamine oxidase, which breaks down neurotransmitters like norepinephrine and serotonin. This leads to an increase in these neurotransmitters in the synapse.

   • Effectiveness: Comparable to tricyclic antidepressants, with fewer side effects. Particularly effective for atypical depression features.

   • Cautions: Can lead to severe hypertensive episodes if foods containing tyramine (e.g., cheese, red wine) are consumed. Interactions with common medications can be dangerous, thus they are typically prescribed only when other treatments fail.

4. Tricyclic Antidepressants

   • Historical Context: Previously the most common treatment before SSRIs, now used less frequently.

   • Mechanism: Block reuptake of neurotransmitters, particularly norepinephrine, allowing them to pool in the synapse.

   • Side Effects: Include blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain (averaging at least 13 pounds), and sexual dysfunction. High dropout rates (up to 40%) due to side effects.

   • Risk: Can be lethal in overdose, requiring caution in prescribing, especially for suicidal patients.

St. John’s Wort (Herbal Medication

• Overview: Natural Herb (Hypericum)

  • Popular in Europe with preliminary studies indicating effectiveness better than placebo and comparable to low doses of other antidepressants.

• Concerns: Large

• studies found no benefits compared to placebo, and there is variability in ingredient quality across brands.

Most commonly Prescribed Antidepressants: Classes, Drug Names, Dosages, and Side Effects:

Treatment-Resistant Depression

• Statistics: Antidepressants relieve symptoms in about 50% of patients, with remission rates of 25% to 30%.

• STAR*D Study: This large study examined alternatives for those not achieving remission, finding:

  • About 20% of patients switched to a second drug achieved remission.

  • Adding a second drug yielded a 30% remission rate.

  • Third drug trials resulted in lower remission rates (10%-20%).

• Conclusion: Persistence with alternative medications can yield improvements for some individuals.

Age-Related Considerations

• Children and Adolescents: Research indicates that drug treatments effective in adults may not be effective in children. Reports of sudden deaths in children taking tricyclics highlight the need for caution.

  • Fluoxetine (Prozac) has shown safety and some efficacy in adolescents, particularly when combined with cognitive behavioral therapy (CBT).

• Elderly: Traditional antidepressant treatments can be effective, but prescribing requires care due to unique side effects (e.g., memory impairment). A depression care manager model has shown more effectiveness than usual care.

Long-Term Management and Recovery

• Therapeutic Goals: While recovery from depression is important, delaying or preventing future episodes is often the primary goal, especially in patients with chronic symptoms or multiple episodes.

• Maintenance Treatment: Continuing drug treatment for 6 to 12 months after an episode may help prevent relapse, with gradual withdrawal of medication.

• Long-Term Risks: There is limited research on long-term antidepressant use, with some evidence suggesting it could worsen depression over several years.

Concerns with Medication

• General Issues: Many patients refuse or are ineligible for antidepressants due to fears of long-term side effects.

• Pregnancy Considerations: Pregnant women must weigh the risks of SSRIs against potential fetal harm.

  • Studies show infants of mothers taking SSRIs may have higher risks for low Apgar scores, but other research suggests SSRIs may lower risks for birth complications.

Lithium as a Mood Stabilizer

• Usage: Lithium carbonate is primarily used for mood stabilization in bipolar disorder, often effective in preventing manic episodes.

• Side Effects: Requires careful dosage regulation to prevent toxicity and thyroid issues. Weight gain is a common side effect.

• Effectiveness: About 50% of bipolar patients respond well to lithium. However, many may find inadequate benefit or discontinue use to regain the manic state.

• Alternatives: Other medications like anticonvulsants (e.g., carbamazepine, valproate) and calcium channel blockers can be alternatives but may be less effective in preventing suicide compared to lithium.

Relapse Rates

• Longitudinal Studies: Approximately 70% of patients on lithium may relapse within 5 years despite ongoing treatment.

• Compliance Issues: Many patients stop taking lithium due to the pleasurable effects of mania, highlighting the need for psychological strategies to improve medication adherence.

Electroconvulsive Therapy and Transcranial Magnetic Stimulation

Overview

• Severe Mood Disorder Treatment: For patients with severe depression who do not respond to medications, alternative treatments like Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS) are considered.

• Electroconvulsive Therapy (ECT): ECT is a safe and effective option that induces controlled seizures to alleviate severe depressive symptoms, especially in psychotic cases. However, a high relapse rate necessitates ongoing follow-up treatment.

• Transcranial Magnetic Stimulation (TMS): TMS is a non-invasive technique using magnetic fields to stimulate brain areas related to mood regulation. While promising, ECT has shown greater effectiveness in severe cases, though TMS may be beneficial when combined with medications.

Electroconvulsive Therapy (ECT)

• Indication: Considered when patients do not respond to medication or in extremely severe cases of depression.

• Controversy: ECT is one of the most controversial treatments for psychological disorders, following psychosurgery.

• Evolution: Although it faced significant criticism in the past, modern ECT is regarded as a safe and effective treatment for severe depression that does not respond to other therapies.

Administration of ECT

• Preparation: Patients receive anesthesia to minimize discomfort and muscle relaxants to prevent injuries during seizures.

• Procedure:

  • An electric shock is administered to the brain for less than a second.

  • This induces a seizure, resulting in a series of brief convulsions lasting several minutes.

• Treatment Schedule: Typically conducted once every other day for a total of 6 to 10 sessions, with fewer sessions if the patient’s mood improves.

Side Effects of ECT

• Common Short-term Effects:

  • Memory loss and confusion that typically resolve within a week or two.

• Potential Long-term Effects: Some patients may experience lasting memory problems.

Efficacy of ECT

• Success Rate: About 50% of severely depressed inpatients with psychotic features show improvement with ECT when medications fail.

• Relapse Rates:

  • After ECT, the relapse rate for depression approaches 60% or higher without continued treatment.

  • A study showed that all patients assigned to placebo relapsed within 6 months, while 40% to 60% of those on antidepressants did not relapse.

• Urgency of Treatment: For psychotically depressed and acutely suicidal inpatients, ECT may be preferred due to the need for immediate intervention rather than waiting for medication or psychotherapy to take effect.

Mechanism of Action

• Unknown Mechanism: The exact reason why ECT works is still not fully understood.

• Possible Effects: Evidence suggests ECT may:

  • Increase serotonin levels in the brain.

  • Block stress hormones.

  • Promote neurogenesis (the growth of new neurons) in the hippocampus.

Transcranial Magnetic Stimulation (TMS)

• Introduction: A newer method that alters brain electrical activity using a magnetic coil placed over the head to generate localized electromagnetic pulses.

• Procedure:

  • Anesthesia is not required.

  • Side effects are generally limited to mild headaches.

Efficacy of TMS

• Initial Findings: Early reports indicated promise in treating depression, and subsequent studies have confirmed its effectiveness.

• Comparative Effectiveness: Clinical trials indicate that ECT is more effective than TMS for severe or treatment-resistant psychotic depression.

• Comparison to Antidepressants:

  • TMS appears more comparable to antidepressant medication than to ECT.

  • A study indicated a slight advantage for combining TMS with medication versus using either treatment alone.

Other Non-Drug Treatments

• Vagus Nerve Stimulation:

  • Involves implanting a device that sends electrical pulses to the vagus nerve in the neck.

  • This is thought to influence neurotransmitter production in the brainstem and limbic system.

  • Although FDA-approved, results have been generally weak, and the procedure is infrequently used.

• Deep Brain Stimulation:

  • Involves surgically implanting electrodes in the limbic system (the area of the brain associated with emotions).

  • These electrodes are connected to a pacemaker-like device.

  • Initial results show promise for treatment-resistant patients, but further research is needed to determine long-term effectiveness.

Cognitive-Behavioral Therapy (CBT)

Overview:

• Based on the observation that deep-seated negative thinking contributes to depression.

• Clients learn to examine their thought processes and identify "depressive" errors in thinking.

Core Components:

• Recognition of Automatic Thoughts: Clients learn that many thoughts occur automatically and are often unaware of them.

• Cognitive Errors: Identification and correction of cognitive errors that lead to depressive feelings.

• Negative Cognitive Schemas: Targeting underlying schemas that trigger cognitive errors.

• Socratic Method: The therapist uses questions to facilitate the client’s exploration of faulty thinking patterns.

Client Interaction Example:

• Dialogue between Therapist and Client (Irene):

  Therapist (T): What kind of thoughts go through your mind when you’ve had these sad feelings this past week?

  Patient (P): Well . . . I guess I’m thinking what’s the point of all this. My life is over. It’s just not the same. . . . I have thoughts like, “What am I going to do? . . . Sometimes I feel mad at him, you know my husband. How could he leave me? Isn’t that terrible of me? What’s wrong with me? How can I be mad at him? He didn’t want to die a horrible death. . . . I should have done more. I should have made him go to the doctor when he first started getting headaches. . . . Oh, what’s the use. . . .”

  T: It sounds like you are feeling quite bad right now. Is that right?

  P: Yes.

  T: Keep telling me what’s going through your mind right now.

  P: I can’t change anything. . . . It’s over. . . . I don’t know. . . . It all seems so bleak and hopeless. . . . What do I have to look forward to . . . sickness and then death. . . .

  T: So one of the thoughts is that you can’t change things and that it’s not going to get any better?

  P: Yes.

  T: And sometimes you believe that completely?

  P: Yeah, I believe it, sometimes.

  T: Right now do you believe it?

  P: I believe it—yes.

  T: Right now you believe that you can’t change things and it’s not going to get better?

  P: Well, there is a glimmer of hope but it’s mostly. . . .

  T: Is there anything in your life that you kind of look forward to in terms of your own life from here on?

  P: Well, what I look forward to—I enjoy seeing my kids, but they are so busy right now. My son is a lawyer and my daughter is in medical school. . . . So, they are very busy. . . . They don’t have time to spend with me.

  • Irene shares her feelings of hopelessness, expressing thoughts like “my life is over.”

  • The therapist helps her articulate these thoughts and reflects on her feelings, encouraging a discussion about potential glimmers of hope.

Related Approaches:

• Cognitive-Behavioral Analysis System of Psychotherapy (CBASP):

  • Integrates cognitive, behavioral, and interpersonal strategies focused on problem-solving skills, particularly for chronic depression.

• Mindfulness-Based Therapy:

  • Found effective for treating depression and preventing relapse; includes Mindfulness-Based Cognitive Therapy (MBCT), particularly effective for those with multiple prior depressive episodes.

Activity and Exercise:

• Increasing activities can improve self-concept and alleviate depression.

• Programmed aerobic exercise has shown efficacy equivalent to antidepressants and is effective in preventing relapse, especially when continued post-treatment.

Interpersonal Psychotherapy (IPT)

• Focus:

  • Addresses interpersonal relationship issues as key stressors in mood disorders.

  • Aims to resolve problems in existing relationships and to form new significant relationships.

• Structure:

  • Highly structured therapy, typically lasting 15-20 sessions scheduled weekly.

  • Involves identifying life stressors and current interpersonal problems.

• Interpersonal Issues Addressed:

  • Role Disputes: Conflicts in relationships, e.g., marital issues.

  • Loss of Relationships: Grieving over lost relationships.

  • Acquiring New Relationships: Challenges in establishing new connections.

  • Social Skills Deficits: Improving skills to initiate and maintain relationships.

• Resolution Process:

  • Identifying stages of disputes:

    • Negotiation Stage: Awareness of the dispute; attempts to renegotiate.

    • Impasse Stage: Underlying resentment without resolution attempts.

    • Resolution Stage: Actions taken toward resolution, such as separation or reconciliation.

Effectiveness of Psychological Treatments

• Psychological approaches (CBT and IPT) have been shown to be as effective as antidepressants in treating major depressive disorder and persistent depressive disorder.

• About 50% of individuals benefit significantly from treatment compared to 30% in placebo/control conditions.

• Studies indicate similar effectiveness in children and adolescents with depression.

Prevention of Mood Disorders

• Importance of preventing mood disorders in children and adolescents has been recognized.

• Types of Prevention Programs:

  • Universal Programs: Applied to everyone.

  • Selected Interventions: Target individuals at risk due to factors like family issues.

  • Indicated Interventions: For individuals showing mild symptoms of depression.

• Research Examples:

  • Gillham et al. (2012): Middle school children trained in cognitive and social problem-solving showed fewer depressive symptoms than a control group.

  • Seligman et al. (1999): University students with a pessimistic cognitive style benefited from an eight-session program, experiencing less anxiety and depression over three years.

• Key Findings from Clinical Trials:

  • A trial with adolescents at risk due to parental depression found CBT to be significantly more effective than usual care in preventing future depressive episodes.

  • Parental depression diminished the efficacy of prevention programs, highlighting the need for coordinated family treatment.

• Broader Implications:

  • Effective prevention strategies are being explored for adults, including in primary care and high-risk populations.

  • Emphasis on the need for further research on prevention methods to address the societal burden of depression.

Combined Treatments for Depression?

Key Question

• Is combining psychosocial treatments with medication more effective than either treatment alone for treating depression or preventing relapse?

Study Overview

• A significant study involving 681 patients was conducted across 12 clinics to evaluate the treatment of persistent (chronic) major depression.

• Patients were assigned to one of three treatment groups:

  • Antidepressant Medication: Specifically nefazodone.

  • Cognitive Behavioral Therapy (CBT): A version designed for chronically depressed patients, known as Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

  • Combination Treatment: Patients received both medication and CBT.

Findings

• Remission Rates:

  • 48% of patients receiving either the antidepressant medication or CBT alone achieved remission or responded in a clinically satisfactory way.

  • 73% of patients receiving the combined treatment went into remission or showed a clinically satisfactory response.

• Implications: The results suggest that combined treatment may be more effective than individual treatments alone, but further research is needed to confirm these findings across broader populations of depressed patients.

Considerations

• The study focused specifically on patients with persistent depression, so the effectiveness of combined treatment for depression in general is still uncertain.

• A limitation of the study is the lack of a condition where CBT was combined with a placebo, making it difficult to rule out the influence of placebo effects on the enhanced effectiveness of the combined treatment.

Expert Consensus

• While there is a general agreement that combined treatment offers some advantage, it is also recognized that combining two treatments can be expensive.

• Many experts advocate for a sequential treatment strategy, where treatment begins with one method (based on patient preference or convenience) and only switches to another if the initial treatment is not fully satisfactory.

Preventing Relapse of Depression

Treatment Effectiveness

• Medications and Cognitive Behavioral Therapy (CBT) operate differently; effectiveness may depend on individual patient characteristics.

• Medications generally act faster, while psychological treatments (like IPT) enhance long-term social functioning and reduce relapse.

Combination Approaches

• Using both medications and psychotherapy may optimize rapid drug action and long-term psychological benefits, allowing for eventual medication discontinuation.

Recurrence Rates

• Over 50% of patients relapse within 4 months after stopping antidepressants, highlighting the need for long-term maintenance treatment.

Cognitive Therapy Efficacy

• Cognitive therapy can reduce relapse rates by more than 50% compared to antidepressant-only treatment.

Jarrett et al. Study (2013)

• In a study of patients with recurrent major depression, initial CBT followed by randomization to continued CBT, fluoxetine, or placebo showed no significant difference in relapse prevention between CBT and fluoxetine over 2 years.

DeRubeis et al. Study (2005)

• In a 2-year follow-up, patients stopping antidepressants for placebo had a higher relapse rate (52.8%) than those continuing medication (23.8%).

• 69.2% of those with prior cognitive therapy did not relapse, indicating lasting effects comparable to ongoing medication.

Stangier et al. Study (2013)

• CBT was only more effective than psychoeducation for patients with five or more previous depressive episodes.

Early Intervention Importance

• Early CBT for high-risk adolescents was more effective than usual care in preventing depression over 3 and 6 years post-treatment.

Conclusion

• Psychological treatments, especially CBT, significantly prevent relapse or recurrence of depression, particularly in chronic or severe cases.

Psychological Treatments for Bipolar Disorder

Importance of Psychological Interventions

• While medication, particularly lithium, is necessary for treating bipolar disorder, psychological interventions are crucial for managing interpersonal and practical problems, such as marital and job difficulties.

• Historically, the main goal of psychological intervention was to increase compliance with medication regimens. Patients in manic states often refuse lithium, making adherence a significant therapeutic challenge.

Need for Medication Compliance

• Skipping dosages or discontinuing medication between episodes undermines treatment effectiveness.

• Research showed that combining psychological treatment with medication improves adherence and outcomes, particularly for severe patients.

Interpersonal and Social Rhythm Therapy (IPSRT)

• Developed by Ellen Frank and colleagues, IPSRT focuses on regulating circadian rhythms by helping patients manage eating and sleep cycles and cope with stressful interpersonal issues.

• Patients receiving IPSRT experienced longer periods without manic or depressive episodes compared to those receiving standard clinical management.

• Initial findings with adolescents indicate promising results.

Family-Focused Treatment

• Research by David Miklowitz and colleagues found a link between family tension and relapse in bipolar disorder.

• Family-focused treatment helps families understand symptoms and develop coping skills, improving communication and preventing relapse.

• In a study, only 35% of patients receiving family therapy plus medication relapsed within a year, compared to 54% in the comparison group.

• Patients undergoing family therapy also had a longer average time before relapse (73.5 weeks) compared to those receiving crisis management.

Effectiveness of Psychological Treatments

• A comparison study showed family-focused therapy had advantages over individualized psychotherapy in maintaining longer-term benefits.

• Some evidence suggests that cognitive-behavioral therapy (CBT) is effective for patients with rapid-cycling bipolar disorder.

• A significant study indicated that up to 30 sessions of intensive psychological treatment were more effective than usual care in promoting recovery from bipolar depression.

Preventive Interventions for High-Risk Youths

• A recent trial compared family-focused therapy to an educational control for youths at high risk of developing bipolar disorder due to family history and environmental factors.

• Participants in family-focused therapy showed faster recovery from mood symptoms and higher remission rates over one year than those in the educational control group.

Conclusion

• The specificity of these treatments for bipolar depression, which is the most common stage of bipolar disorder, combined with the ineffectiveness of antidepressants for this stage, suggests that psychological interventions are essential in the comprehensive treatment of bipolar disorder.

• Otto and colleagues have synthesized evidence-based psychological treatment procedures for bipolar disorder into a new treatment protocol.

Suicide (An Overview)

• Prevalence and Public Awareness

  • Suicide is a significant public health issue, ranking as one of the leading causes of death in the United States.

  • Approximately 40,000 people die by suicide each year in the U.S., highlighting the severity of this crisis.

• Comparison to Other Health Issues

  • While there is extensive media coverage on diseases like cancer and AIDS, suicide often receives less attention, despite its high mortality rate.

  • Public health campaigns typically focus on preventive measures for physical health conditions, such as diet and exercise to combat heart disease.

• The Nature of the Decision to End Life

  • The act of suicide is often described as seemingly inexplicable, indicating the complex psychological factors that contribute to this tragic decision.

  • Understanding the reasons behind suicide requires a nuanced approach that considers mental health issues, societal pressures, and personal circumstances.

• Importance of Awareness

  • Greater awareness and understanding of suicide are necessary to address its causes effectively and to develop strategies for prevention.

Statistics

• General Overview of Suicide

  • In a randomly selected group of 1,000 people:

    • 4 will commit suicide annually.

    • 7 will make plans to kill themselves.

    • 20 will seriously consider suicide.

• Suicide as a Leading Cause of Death

  • Suicide is the 11th leading cause of death in the United States.

  • Epidemiologists suggest the actual number of suicides may be 2 to 3 times higher than reported.

    • Unreported suicides often occur through means like driving off cliffs.

    • Historically, some suicides were attributed to medical causes out of respect for the deceased.

  • Globally, suicide results in more deaths per year than homicide or HIV/AIDS.

• Demographic Patterns in Suicide Rates

  • Suicide predominantly affects white individuals, while minority groups like African Americans and Hispanics generally have lower rates.

  • Native Americans exhibit exceptionally high suicide rates, with significant variability across tribes:

    • For example, the Apache tribe's rate is nearly 4 times the national average.

  • Notable increases in suicide rates begin in adolescence:

    • In 2012, suicide rates rose from 1.73 per 100,000 in ages 10-14 to 14.26 per 100,000 in ages 20-24.

    • Firearms are involved in nearly 50% of adolescent suicides, with access being equal among at-risk and non-at-risk youth.

• Suicide Trends in Different Age Groups

  • Elderly Population:

    • Rates among the elderly have increased due to rising medical illnesses and loss of social support, contributing to depression.

  • Children:

    • Children aged 2 to 5 have reported suicide attempts, with suicide being the 5th leading cause of death for ages 5 to 14.

• Gender Disparities in Suicide Rates

  • Worldwide, males are 4 times more likely to commit suicide than females, except in China.

    • Males typically use more violent methods (e.g., guns, hanging) while females opt for less lethal means (e.g., drug overdose).

  • In China, the trend reverses, with more women than men committing suicide, particularly in rural areas:

    • Cultural perceptions portray suicide as a reasonable solution to familial issues.

• Indicators of Suicidal Behavior

  • Suicidal Ideation: Serious thoughts about suicide.

  • Suicidal Plans: Specific methods considered for committing suicide.

  • Suicidal Attempts: Attempts where the individual survives.

  • Distinction is made between "attempters" (those intending to die) and "gesturers" (those intending to communicate distress).

• Prevalence of Suicidal Thoughts and Actions

  • A cross-national study estimated:

    • 9.2% experienced suicidal ideation.

    • 3.1% formulated a suicide plan.

    • 2.7% attempted suicide during their lifetime.

  • Females attempt suicide at least 3 times more than males, despite males having higher completion rates.

    • Nonlethal suicidal thoughts and attempts are 40% to 60% higher in women.

  • Among adolescents, the ratio of suicidal thoughts to attempts is between 3:1 and 6:1:

    • 16% to 30% of adolescents who contemplate suicide will attempt it.

• Suicidal Thoughts Among College Students

  • Suicide is the 2nd leading cause of death among college students.

  • Approximately 12% have had serious thoughts about suicide in the past year.

  • Only about 10% of these students attempt suicide, and fewer succeed, highlighting the seriousness with which mental health professionals treat suicidal thoughts.

Causes

• Bernard Loiseau's Suicide (2003)

  • In spring 2003, renowned French chef Bernard Loiseau faced a significant setback when the Gault Millau restaurant guide reduced the rating of one of his establishments.

  • This marked the first time in his career that any of his restaurants had received a lower rating.

  • Shortly after this event, Loiseau took his own life.

  • Although police ruled his death a suicide, many in France, including fellow chefs, did not accept this classification. They accused the guidebook of "murder," claiming Loiseau was profoundly affected by the rating decrease and the press speculation regarding a potential loss of one of his three Michelin stars.

  • This incident sparked widespread discussion in France and the culinary world about the causes of suicide.

• Past Conceptions of Suicide

  • Emile Durkheim's Definitions:

    • The prominent sociologist Emile Durkheim categorized suicides based on social or cultural conditions:

      • Altruistic Suicide:

        • Refers to suicides that are socially approved or formalized, such as the Japanese practice of hara-kiri, where individuals who brought dishonor to themselves or their families were expected to commit suicide.

      • Egoistic Suicide:

        • Occurs due to a lack of social support, such as older adults who take their lives after losing contact with friends or family.

        • A study showed that only 13% of individuals who had seriously attempted suicide had a sufficient social network, indicating a significant lack of support.

        • Suicide attempters also perceived themselves as having lower social support compared to non-attempters.

      • Anomic Suicide:

        • Results from significant disruptions or changes, such as the sudden loss of a prestigious job. This state, known as anomie, involves feelings of being lost or confused.

      • Fatalistic Suicide:

        • Arises from a perceived loss of control over one’s life, exemplified by the mass suicide of 39 members of the Heaven's Gate cult, who were under the strong influence of their leader, Marshall Applewhite.

• Psychological Perspectives

  • Sigmund Freud's View:

    • Freud suggested that suicide reflects unconscious hostility directed inward toward oneself, rather than outward toward others or situations that cause anger.

    • Victims of suicide may psychologically "punish" those who have rejected them or caused personal pain.

• Current Understanding

  • Contemporary perspectives on suicide emphasize a combination of social, psychological, and biological factors that contribute to suicidal behavior.

Risk Factors

Pioneering Research

• Edward Shneidman studied risk factors for suicide using methods such as psychological autopsy.

• Psychological autopsy reconstructs the deceased's mental state through interviews with friends and family, revealing key risk factors for suicide.

Family History

• Increased Risk in Families

  • A family history of suicide significantly raises the likelihood of suicide in other family members.

  • Strongest predictor of suicidal behavior among depressed patients is a family history of suicide.

  • Children of family members who attempted suicide are six times more likely to attempt suicide than those without such a history.

  • If a sibling has attempted suicide, the risk escalates further.

• Influencing Factors

  • Mental disorders, including depression, often run in families, contributing to the risk.

  • Both observational (imitative behavior) and inherited traits (like impulsivity) may contribute to increased suicidal behavior within families.

  • Early onset of mood disorders and traits like aggression or impulsivity elevate family suicide risk.

• Genetic Factors

  • Adoption studies show higher suicide rates among biological relatives of adoptees who committed suicide, suggesting a genetic influence.

  • Suicidal behavior in adopted individuals is more closely predicted by biological relatives than adopted families, indicating a genetic component, albeit possibly linked to mood disorders.

Neurobiology

• Serotonin Levels

  • Evidence suggests low serotonin levels correlate with suicide risk and violent attempts.

  • Extremely low serotonin may lead to impulsivity, instability, and overreaction, increasing the likelihood of impulsive actions, including suicide.

Existing Psychological Disorders and Other Psychological Risk Factors

• Prevalence of Disorders

  • Over 80% of individuals who commit suicide have a psychological disorder, typically mood, substance use, or impulse control disorders.

  • Approximately 60% of all suicides (75% of adolescent suicides) are associated with mood disorders.

• Relationship Between Mood Disorders and Suicide

  • Not all individuals with mood disorders attempt suicide; conversely, many who attempt suicide do not have mood disorders.

  • Hopelessness is identified as a strong predictor of suicide, not only in those with depression but also in individuals with other mental health issues.

  • The "interpersonal theory of suicide" highlights feelings of being a burden and lack of belonging as predictors of hopelessness and suicide.

• Alcohol Use and Abuse

  • Alcohol use is linked to 25%-50% of suicides, notably among college students and adolescents.

  • About one-third of adolescents who commit suicide are intoxicated, with many others possibly under the influence of drugs.

  • Combinations of disorders (e.g., substance abuse with mood disorders) create a stronger vulnerability than single disorders alone.

• Past Suicide Attempts

  • A strong risk factor; individuals with previous attempts must be taken seriously.

  • Research indicates that nearly 8,000 individuals treated for self-harm had a suicide rate 30 times higher than the general population.

• Borderline Personality Disorder

  • Characterized by impulsivity, often leads to manipulative suicidal gestures without intent to die.

  • The combination of borderline personality disorder with depression increases the risk of successful suicide.

Stressful Life Events

• Significant Stressors

  • Severe, shameful, or humiliating events (e.g., academic failure, unexpected arrest, rejection) are critical risk factors for suicide.

  • Physical and sexual abuse are significant stress sources that increase suicide risk.

• Impact of Natural Disasters

  • Natural disasters contribute to increased suicide rates; for instance, rates rose significantly after floods, hurricanes, and earthquakes.

  • Preexisting vulnerabilities (mental disorders, impulsivity, lack of support) can be exacerbated by stressful events, potentially leading to suicidal behavior.

• Therapeutic Interventions

  • Cognitive behavioral group therapy has been effective in reducing suicidal behavior in individuals with previous attempts.

• Integrated model of the causes of suicidal behavior

  

Is Suicide Contagious?

• Reactions to Suicide News

  • Most individuals respond to suicide news with sadness and curiosity.

  • Some individuals may react by attempting suicide themselves, often using the same method reported in the news.

• Research Findings on Suicide Contagion

  • Increase in Suicides: A study by Gould (1990) indicated an increase in suicides during a 9-day period following extensive media coverage of a suicide.

  • Positive Relationship with Media Exposure: A review showed a positive correlation between suicidal behavior and exposure to media coverage about suicide, indicating that increased media attention can lead to more suicidal actions (Sisask & Varnik, 2012).

• Imitation Suicides Among Teenagers

  • Clusters of suicides are particularly prevalent among teenagers, with as many as 5% of teenage suicides reflecting imitation of others (Gould, 1990; Gould et al., 2003).

• Reasons for Imitation

  • Romanticization in Media: Media often romanticizes suicides, depicting them as heroic acts. For instance, an attractive young person under pressure may be portrayed as a martyr, eliciting admiration from peers.

  • Detailed Method Descriptions: Media reports frequently provide explicit details about the methods used, which can serve as a guide for potential victims.

  • Lack of Coverage on Consequences: There is minimal reporting on the tragic outcomes of failed suicides, such as paralysis or brain damage, and little acknowledgment of the severe psychological disorders commonly associated with suicide.

  • Understating the Ineffectiveness: Media often fails to discuss the futility of suicide as a problem-solving method.

• Prevention Measures

  • To prevent suicide contagion, mental health professionals must intervene promptly in schools and other settings where individuals may be vulnerable to the influence of suicide.

• Understanding Suicide Contagion

  • It is unclear whether suicide is “contagious” in a manner similar to infectious diseases.

  • Instead, the stress resulting from a friend's suicide or other significant life stressors may impact individuals who are already vulnerable due to pre-existing psychological disorders.

• Uncertainty in Predicting Suicide

  • Suicide prediction remains difficult despite the identification of key risk factors.

  • Some individuals with few apparent risks may unexpectedly commit suicide.

  • Conversely, many people facing severe stress and illness manage to survive.

• Assessment of Suicidal Ideation

  • Mental health professionals are trained to assess suicidal thoughts and behaviors.

  • There is often reluctance among others to ask about suicide for fear of suggesting the idea.

  • It is crucial to address suicidal thoughts rather than avoid the topic; the risk of suggesting suicide is minimal compared to the risk of leaving thoughts undiscovered.

• Research Findings

  • A study involving over 1,000 high school students showed that those asked about suicidal thoughts during screenings did not exhibit increased suicidal ideation compared to those who were not asked.

• Identifying Suicidal Risk

  • Professionals inquire if individuals have experienced thoughts about life not being worth living or have considered self-harm.

  • Implicit Thoughts:

    • Some individuals may have unconscious suicidal thoughts.

    • An implicit association test using a Stroop task revealed that individuals unconsciously linking death or suicide to themselves were six times more likely to attempt suicide within six months.

• Assessing Suicidal Risk Factors

  • Clinicians evaluate the following:

    • Suicidal Desire: Feelings of hopelessness, burdensomeness, and feeling trapped.

    • Suicidal Capability: Past attempts, high anxiety, available means for suicide.

    • Suicidal Intent: Existence of a detailed plan, expressed intent to die, preparatory behaviors.

  • A detailed plan involving specific timing, location, and method indicates a higher risk of suicide.

  • Understanding the potential consequences of chosen methods is essential.

  • Taking precautions against being discovered heightens risk.

• Intervention Strategies

  • If suicidal risk is identified, clinicians may have individuals agree to a "no-suicide" contract, promising to contact their mental health professional before taking any action.

  • If an individual refuses or if risk is deemed high, immediate hospitalization may be necessary, regardless of the patient’s wishes.

  • Treatment should focus on addressing life stressors and psychological disorders immediately, whether the individual is hospitalized or not.

• Public Health Initiatives

  • Various programs have been developed to reduce suicide rates.

  • Universal programs targeting the general population (e.g., school curricula) have proven largely ineffective.

  • Targeted programs for at-risk individuals, especially following a suicide, show more promise.

  • Recommendations include providing immediate support services to the friends and family of suicide victims.

  • Limiting access to lethal means, such as firearms, has been identified as a powerful prevention strategy.

  • Crisis intervention services, including hotlines, are beneficial but require support from qualified mental health professionals.

• Specific Treatment Approaches

  • Suicide prevention programs for the elderly focus on reducing risk factors, such as treating depression, rather than enhancing protective factors like familial support.

  • Other interventions target specific mental health issues linked to suicide.

  • Cognitive-Behavioral Interventions: Research indicates effectiveness in reducing suicide risk.

    • A brief psychological treatment for young adults at risk has shown significant reductions in suicidal ideation and behaviors.

    • A study revealed that 10 sessions of cognitive therapy for recent suicide attempters reduced the risk of further attempts by 50% over 18 months (24% in the therapy group versus 42% in standard care).

• Continued Focus on Suicide Prevention

  • With rising suicide rates, particularly among adolescents, public health scrutiny is increasing.

  • Efforts will continue to find more effective methods to prevent suicide, one of the most severe consequences of psychological disorders.

Solution

Solution

• Uncertainty in Predicting Suicide

  • Suicide prediction remains difficult despite the identification of key risk factors.

  • Some individuals with few apparent risks may unexpectedly commit suicide.

  • Conversely, many people facing severe stress and illness manage to survive.

• Assessment of Suicidal Ideation

  • Mental health professionals are trained to assess suicidal thoughts and behaviors.

  • There is often reluctance among others to ask about suicide for fear of suggesting the idea.

  • It is crucial to address suicidal thoughts rather than avoid the topic; the risk of suggesting suicide is minimal compared to the risk of leaving thoughts undiscovered.

• Research Findings

  • A study involving over 1,000 high school students showed that those asked about suicidal thoughts during screenings did not exhibit increased suicidal ideation compared to those who were not asked.

• Identifying Suicidal Risk

  • Professionals inquire if individuals have experienced thoughts about life not being worth living or have considered self-harm.

  • Implicit Thoughts:

    • Some individuals may have unconscious suicidal thoughts.

    • An implicit association test using a Stroop task revealed that individuals unconsciously linking death or suicide to themselves were six times more likely to attempt suicide within six months.

• Assessing Suicidal Risk Factors

  • Clinicians evaluate the following:

    • Suicidal Desire: Feelings of hopelessness, burdensomeness, and feeling trapped.

    • Suicidal Capability: Past attempts, high anxiety, available means for suicide.

    • Suicidal Intent: Existence of a detailed plan, expressed intent to die, preparatory behaviors.

  • A detailed plan involving specific timing, location, and method indicates a higher risk of suicide.

  • Understanding the potential consequences of chosen methods is essential.

  • Taking precautions against being discovered heightens risk.

• Intervention Strategies

  • If suicidal risk is identified, clinicians may have individuals agree to a "no-suicide" contract, promising to contact their mental health professional before taking any action.

  • If an individual refuses or if risk is deemed high, immediate hospitalization may be necessary, regardless of the patient’s wishes.

  • Treatment should focus on addressing life stressors and psychological disorders immediately, whether the individual is hospitalized or not.

• Public Health Initiatives

  • Various programs have been developed to reduce suicide rates.

  • Universal programs targeting the general population (e.g., school curricula) have proven largely ineffective.

  • Targeted programs for at-risk individuals, especially following a suicide, show more promise.

  • Recommendations include providing immediate support services to the friends and family of suicide victims.

  • Limiting access to lethal means, such as firearms, has been identified as a powerful prevention strategy.

  • Crisis intervention services, including hotlines, are beneficial but require support from qualified mental health professionals.

• Specific Treatment Approaches

  • Suicide prevention programs for the elderly focus on reducing risk factors, such as treating depression, rather than enhancing protective factors like familial support.

  • Other interventions target specific mental health issues linked to suicide.

  • Cognitive-Behavioral Interventions: Research indicates effectiveness in reducing suicide risk.

    • A brief psychological treatment for young adults at risk has shown significant reductions in suicidal ideation and behaviors.

    • A study revealed that 10 sessions of cognitive therapy for recent suicide attempters reduced the risk of further attempts by 50% over 18 months (24% in the therapy group versus 42% in standard care).

• Continued Focus on Suicide Prevention

  • With rising suicide rates, particularly among adolescents, public health scrutiny is increasing.

  • Efforts will continue to find more effective methods to prevent suicide, one of the most severe consequences of psychological disorders.