Mood Disorders Comprehensive Study Notes

Mood Disorders Core Concepts

  • Focus of the lecture: mood disorders, primarily depression and bipolar disorders; includes discussion of suicidality (addressed at the end).

  • Depression terminology can be confusing: we distinguish between mood state (depressed mood) and disorder (pathology with impairment).

  • Mood state vs disorder:

    • Mood state: a longer-term mood that can affect thoughts and functioning but is not by itself a disorder.

    • Disorder: characterized by dysfunction/impairment beyond what is typical, in terms of frequency, duration, and severity.

  • Major depressive episode (MDE): a period of depressed mood that meets DSM criteria; a symptom, not a disorder, and can occur in several different disorders.

  • Major depressive disorder (MDD): a specific disorder characterized by at least one MDE, plus clinically significant impairment, not due to substances or another medical condition, and no history of mania or hypomania (unipolar).

  • “Clinical depression” is a colloquial term and not an official DSM term; it often refers to a major depressive episode that meets DSM criteria.

  • Mood spectrum/continuum: depression and mania conceptualized on a continuum from severe depression to mania, with euthymia (neutral mood) in the middle.

  • Euthymia: neutral mood, no strong emotions; a clinical term to describe a baseline state.

  • Typical mood range on the continuum includes sadness (left) and happiness (right); mild depression (dysthymia) and severe depression are placed on the left; elation/hypomania and mania on the right.

  • Mixed features: mood periods can involve symptoms from both ends of the spectrum (e.g., depressive symptoms with some manic symptoms).

  • Disorders can be episodic (major depressive episodes, manic episodes) or chronic (e.g., persistent depressive disorder).

  • Distinction between unipolar mood disorders (depression alone) and bipolar disorders (depression and mania/hypomania).

  • In clinical practice, the term episode refers to a symptom cluster, not a disorder; diagnosis relies on the overall pattern across time.

Mood Continuum: Diagrammatic Concept

  • Euthymia: neutral mood (center of the diagram).

  • Left side: typical sadness to mild depression (including dysthymia) and then severe depression (major depressive episode).

  • Right side: elation/hypomania then mania; psychosis can accompany severe mania.

  • Mixed features: symptoms from both sides can occur in the same period.

  • Unipolar Mood Disorder: depressive pole only (classic depressive disorders).

  • Bipolar Disorder: oscillation between depressive and manic poles.

  • Important note: some individuals can present with components of both sides at once, which can complicate diagnosis.

Depressive Disorders: Overview and Criteria

  • Major depressive episode (MDE) criteria: a symptom-based episode with specific DSM criteria; occurs in multiple disorders, not just MDD.

  • MDD requires at least one MDE and significant impairment, not due to substances or another medical condition, with no history of mania or hypomania (unipolar).

  • Specifiers for Major Depressive Disorder:

    • with psychotic features: psychosis includes hallucinations or delusions; indicates more severe MDD.

    • anxious distress: significant anxiety symptoms accompanying depression; comorbidity increases complexity and often worsens prognosis.

    • mixed features: concurrent manic/hypomanic symptoms with a depressive episode (but not a full manic episode).

    • catatonic: marked motor symptoms (e.g., waxy flexibility, purposeless movements).

    • peripartum: onset during pregnancy or after childbirth.

    • seasonal pattern: episodes that occur in a seasonal pattern (often fall/winter; seasonal affective disorder).

  • Major depressive episode (MDE) diagnostic criteria: you must have at least 5 of 9 symptoms during a 2-week period, and at least one of the two core symptoms (1) depressed mood or (2) anhedonia (loss of interest/pleasure).

    • The nine symptoms (numbers refer to their order in the DSM):

    1. Depressed mood most of the day, nearly every day.

    2. Markedly diminished interest or pleasure in all, or almost all, activities (anhedonia).

    3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite.

    4. Insomnia or hypersomnia.

    5. Psychomotor agitation or retardation.

    6. Fatigue or loss of energy.

    7. Feelings of worthlessness or excessive or inappropriate guilt.

    8. Diminished ability to think or concentrate, or indecisiveness.

    9. Recurrent thoughts of death, or recurrent suicidal ideation, with or without a plan, or a suicide attempt.

  • Note: at least five symptoms must be present during the same 2-week period, and at least one of the symptoms must be (1) depressed mood or (2) anhedonia.

  • Duration and frequency: MDE lasts at least 2 weeks2\text{ weeks}.

  • Prevalence and epidemiology for depressive disorders:

    • Lifetime prevalence of MDD: 16%16\%.

    • Annual incidence: ≈6%\approx 6\%.

    • Depression can occur across the lifespan; adolescents may have rates similar to adults.

    • Women are about twice as likely as men to experience mood disorders (risk ratio ≈ 2).

    • The likelihood of MDD shows sex differences that may reflect biology, reporting, and social factors.

  • Persistent depressive disorder (PDD; formerly dysthymia): chronic, lower-severity depression.

    • Criteria: depressed mood for most of the day, more days than not, for at least 2 years2\ years.

    • At least two of the following:

    • Poor appetite or overeating.

    • Insomnia or hypersomnia.

    • Low energy or fatigue.

    • Low self-esteem.

    • Poor concentration or difficulty making decisions.

    • Feelings of hopelessness.

    • During the 2 year2\text{ year} period, the person did not go more than two months without depressive symptoms.

    • Person does not have a history of manic/hypomanic episodes (no cyclothymic disorder).

    • Subtypes/specifiers:

    • Pure dysthymic syndrome: mild depressive symptoms never reaching MDE severity.

    • Persistent major depressive episode: meets MDE criteria but persists over two years.

    • Intermittent depressive, major depressive episodes (double depression): chronic mild depression with superimposed MDE episodes.

  • Other specified depressive disorder and unspecified depressive disorder:

    • Used when symptoms cause clinically significant distress or impairment but do not fully meet criteria for MDD or PDD.

Bipolar Disorders: Overview and Subtypes

  • Common misconceptions about bipolar disorder:

    • Not simply a stereotype of being irritable or flip-flopping emotions; bipolar involves distinct mood episodes (manic/hypomanic and depressive) with specific criteria and impairment.

    • Manic/hypomanic symptoms can occur in other disorders, but a full manic episode requires distinct criteria and impairment.

  • Manic episode criteria:

    • Lasts at least 1 week1\text{ week} (most of the day, nearly every day) or any duration if hospitalization is necessary.

    • Elevated/expansive or irritable mood with increased goal-directed activity or energy.

    • At least three (or four if the mood is only irritable) of the following seven symptoms:

    • Inflated self-esteem or grandiosity.

    • Decreased need for sleep.

    • More talkative than usual or pressure to keep talking.

    • Flight of ideas or subjective experience that thoughts are racing.

    • Distractibility.

    • Increased goal-directed activity or psychomotor agitation.

    • Excessive involvement in high-risk activities with potential negative consequences.

  • Hypomanic episode: milder form of mania with similar symptoms but less impairment.

    • Duration: at least 4 days4\text{ days}.

    • Does not cause marked impairment in social/occupational functioning (unlike a manic episode).

    • Cannot include psychotic features; if psychotic features are present, it is a manic episode.

  • Bipolar I disorder: alternating between depressive or euthymic periods and manic episodes; a full manic episode is required.

  • Bipolar II disorder: alternates between major depressive episodes and hypomanic episodes (no full manic episodes).

  • Cyclothymic disorder: alternating hypomanic and mild depressive periods that do not meet full criteria for a MDE or manic episode.

    • Criteria: lasts at least 2 years2\ years with numerous periods of hypomanic symptoms and depressive symptoms that do not meet criteria for a full episode.

    • Symptoms never go without for more than two months at a time.

    • Mood fluctuations are persistent and chronic rather than having full-blown episodic swings.

  • Rapid cycling (a specifier within Bipolar I):

    • Four or more mood episodes (manic, hypomanic, or depressive) within a 12-month period.

    • Associated with greater severity, higher suicidality risk, and more challenging treatment.

    • Occurs in approximately 20%20\% to 50%50\% of bipolar cases, depending on criteria and sample.

  • Onset and prevalence:

    • Typical onset: 15→2215\to 22 years.

    • Lifetime prevalence of bipolar disorders is about 1%1\% and occurs at roughly equal rates across genders.

  • Suicide risk:

    • Bipolar disorders have a higher risk of suicide attempts and completed suicide compared with the general population; lifetime attempts vary widely (roughly 12% to 48%12\%\text{ to }48\%), with completed suicide about 20x higher than in the general population.

  • Diagnostic considerations:

    • Thorough history is essential; individuals may present during a depressive or euthymic state and have past manic/hypomanic episodes.

    • Onset in adolescence/early adulthood; diagnosis requires longitudinal data, not just current mood.

  • Psychosocial and treatment considerations:

    • Mood episodes are chronic and can recur; treatment plans must adapt to shifting mood states.

    • Psychoeducation and adherence are crucial due to complexity of mood cycling.

Epidemiology and Demographics across Mood Disorders

  • Depression:

    • Lifetime prevalence (MDD): about 16%16\%.

    • Annual prevalence: about 6%6\%.

    • Females: approximately twice as likely as males to experience a mood disorder (i.e., higher female prevalence).

  • Bipolar disorders:

    • Lifetime prevalence: about 1%1\%.

    • Onset: typically in late adolescence/early adulthood (around 15→22$$).</p></li><li><p>Suiciderisk:notablyhigherthaninthegeneralpopulation;deathbysuicideriskiselevatedparticularlyinbipolarpopulations.</p></li></ul></li></ul><h3id="686345c6−1330−41e7−ad66−5f49e0f906f7"data−toc−id="686345c6−1330−41e7−ad66−5f49e0f906f7"collapsed="false"seolevelmigrated="true">Etiology:Biological,Psychological,andSocialFactors</h3><ul><li><p>Biologicalcontributors</p><ul><li><p>Genetics/heredity:substantialgeneticcomponent;heritabilityissignificant;greaterheritabilityinfemalesthanmales.</p></li><li><p>Familystudies:relativeswithmooddisordersare2–3timesmorelikelytohavemooddisorders;amongidenticaltwins,about15\to 22\$\$).</p></li><li><p>Suicide risk: notably higher than in the general population; death by suicide risk is elevated particularly in bipolar populations.</p></li></ul></li></ul><h3 id="686345c6-1330-41e7-ad66-5f49e0f906f7" data-toc-id="686345c6-1330-41e7-ad66-5f49e0f906f7" collapsed="false" seolevelmigrated="true">Etiology: Biological, Psychological, and Social Factors</h3><ul><li><p>Biological contributors</p><ul><li><p>Genetics/heredity: substantial genetic component; heritability is significant; greater heritability in females than males.</p></li><li><p>Family studies: relatives with mood disorders are 2–3 times more likely to have mood disorders; among identical twins, about66\%oftwinswithamooddisorderhaveaco−twinwithamooddisorder;amongfraternaltwins,therateislower(≈of twins with a mood disorder have a co-twin with a mood disorder; among fraternal twins, the rate is lower (≈19\%).</p></li><li><p>Serotoninhypothesis(chemicalimbalance)andlimitations:</p></li><li><p>Thetraditionalserotonindeficiencyhypothesisisnotstronglysupportedbyevidence;antidepressantsdonotnecessarilyworksolelybycorrectingserotonindeficits.</p></li><li><p>Permissivehypothesis:serotoninisinvolvedinregulatingotherneurotransmitters;lowserotoninmaydysregulatemultipleneurotransmittersystemsratherthanbeingthesolecause.</p></li><li><p>Neuroendocrinefactors:theHPAaxisandstresshormones(e.g.,cortisol)areimplicated;theaxiscanbeoveractiveindepression.</p></li><li><p>Neuroplasticity:reducedneurogenesisinthehippocampusunderstress;hippocampushelpsregulatestressresponses.</p></li><li><p>Cognitiveprocessing:memorybiasesandcognitiveprocessingchangesassociatedwithmooddisorders.</p></li></ul></li><li><p>Psychologicalandsocialcontributors</p><ul><li><p>Stress−diathesismodel:geneticpredispositionsinteractwithlifestresstotriggerepisodes.</p></li><li><p>Lackofcontactwithpleasureormastery:participationinpleasurableandmastery−relatedactivitiesisreducedindepression;thisreductioncancontributetoormaintaindepressivestates.</p></li><li><p>Rewardprocessingandhedoniccapacity:anhedoniareflectsreducedabilitytoexperiencepleasureandmastery.</p></li><li><p>Learnedhelplessness:perceivedlackofcontrolincreaseshopelessnessanddepressiverisk;cognitiveandbehavioralpatternsleadtochronicnegativethinking.</p></li><li><p>Beck′scognitivemodelandcognitivedistortions:negativeautomaticthoughts,corebeliefs(e.g.,Iamworthless),andmisinterpretationsofeventscontributetodepression.</p></li><li><p>Socialandculturalfactors:</p></li><li><p>Socialsupportactsasaprotectivefactor;strongersocialnetworkspredictbetterrecoveryandoutcomes,whilelackofsocialsupportpredictspooreroutcomesandlateronset.</p></li><li><p>Systemicfactors(poverty,housinginstability,foodinsecurity,discrimination,racism,unstablefamilyrelationships)increaseriskviastressandlimitedresources.</p></li><li><p>Genderandculture:womenshowhigherratesofMDD;culturalandsocialfactorsinfluencereporting,accesstocare,andstressexposure.</p></li></ul></li><li><p>Otherinfluentialfactors</p><ul><li><p>Lifeeventsandchronicstress(e.g.,COVID−19lockdowns)canprecipitateorworsendepressivestates.</p></li><li><p>Theinterplayofbiologicalpredispositionwithlifecontextyieldsheterogeneityinetiologyandcourse.</p></li></ul></li></ul><h3id="0936c6c3−9860−4844−a342−51a81049b856"data−toc−id="0936c6c3−9860−4844−a342−51a81049b856"collapsed="false"seolevelmigrated="true">TreatmentApproaches:GeneralPrinciples</h3><ul><li><p>Coregoal:reducesymptoms,impairments,andrisk(includingsuicidality),andtohelpclientsbuildalifeworthliving.</p></li><li><p>Treatmentofteninvolvesacombinationofmedicationandpsychotherapy;choicesareindividualized.</p></li><li><p>Pharmacotherapyandpsychotherapyhavecomplementarybenefits;long−termmaintenanceoftenrequiresskill−building(CBT,ACT,DBT,etc.).</p></li><li><p>Treatmentresistance:someindividualsdonotrespondtoinitialtreatments;strategiesincludeaugmentation,switchingagents,oraddingpsychotherapy.</p></li><li><p>Safetyconsiderations:suicidalityriskassessmentisessential;safetyplanningandmeansrestrictionarecritical.</p></li></ul><h3id="187ca819−c121−472f−914d−cf629ebe53cb"data−toc−id="187ca819−c121−472f−914d−cf629ebe53cb"collapsed="false"seolevelmigrated="true">PharmacotherapyAcrossMoodDisorders</h3><ul><li><p>First−lineantidepressantsforunipolardepression:</p><ul><li><p>SSRIsandSNRIsaretypicallysafestwiththefewestsideeffects;onsetusuallytakes).</p></li><li><p>Serotonin hypothesis (chemical imbalance) and limitations:</p></li><li><p>The traditional serotonin deficiency hypothesis is not strongly supported by evidence; antidepressants do not necessarily work solely by correcting serotonin deficits.</p></li><li><p>Permissive hypothesis: serotonin is involved in regulating other neurotransmitters; low serotonin may dysregulate multiple neurotransmitter systems rather than being the sole cause.</p></li><li><p>Neuroendocrine factors: the HPA axis and stress hormones (e.g., cortisol) are implicated; the axis can be overactive in depression.</p></li><li><p>Neuroplasticity: reduced neurogenesis in the hippocampus under stress; hippocampus helps regulate stress responses.</p></li><li><p>Cognitive processing: memory biases and cognitive processing changes associated with mood disorders.</p></li></ul></li><li><p>Psychological and social contributors</p><ul><li><p>Stress-diathesis model: genetic predispositions interact with life stress to trigger episodes.</p></li><li><p>Lack of contact with pleasure or mastery: participation in pleasurable and mastery-related activities is reduced in depression; this reduction can contribute to or maintain depressive states.</p></li><li><p>Reward processing and hedonic capacity: anhedonia reflects reduced ability to experience pleasure and mastery.</p></li><li><p>Learned helplessness: perceived lack of control increases hopelessness and depressive risk; cognitive and behavioral patterns lead to chronic negative thinking.</p></li><li><p>Beck's cognitive model and cognitive distortions: negative automatic thoughts, core beliefs (e.g., I am worthless), and misinterpretations of events contribute to depression.</p></li><li><p>Social and cultural factors:</p></li><li><p>Social support acts as a protective factor; stronger social networks predict better recovery and outcomes, while lack of social support predicts poorer outcomes and later onset.</p></li><li><p>Systemic factors (poverty, housing instability, food insecurity, discrimination, racism, unstable family relationships) increase risk via stress and limited resources.</p></li><li><p>Gender and culture: women show higher rates of MDD; cultural and social factors influence reporting, access to care, and stress exposure.</p></li></ul></li><li><p>Other influential factors</p><ul><li><p>Life events and chronic stress (e.g., COVID-19 lockdowns) can precipitate or worsen depressive states.</p></li><li><p>The interplay of biological predisposition with life context yields heterogeneity in etiology and course.</p></li></ul></li></ul><h3 id="0936c6c3-9860-4844-a342-51a81049b856" data-toc-id="0936c6c3-9860-4844-a342-51a81049b856" collapsed="false" seolevelmigrated="true">Treatment Approaches: General Principles</h3><ul><li><p>Core goal: reduce symptoms, impairments, and risk (including suicidality), and to help clients build a life worth living.</p></li><li><p>Treatment often involves a combination of medication and psychotherapy; choices are individualized.</p></li><li><p>Pharmacotherapy and psychotherapy have complementary benefits; long-term maintenance often requires skill-building (CBT, ACT, DBT, etc.).</p></li><li><p>Treatment resistance: some individuals do not respond to initial treatments; strategies include augmentation, switching agents, or adding psychotherapy.</p></li><li><p>Safety considerations: suicidality risk assessment is essential; safety planning and means restriction are critical.</p></li></ul><h3 id="187ca819-c121-472f-914d-cf629ebe53cb" data-toc-id="187ca819-c121-472f-914d-cf629ebe53cb" collapsed="false" seolevelmigrated="true">Pharmacotherapy Across Mood Disorders</h3><ul><li><p>First-line antidepressants for unipolar depression:</p><ul><li><p>SSRIs and SNRIs are typically safest with the fewest side effects; onset usually takes4\to 6\text{ weeks}.</p></li><li><p>Sideeffectsvarybymedicationandindividual;possibleeffectsincludesleepdisturbances,nausea,headaches,changesinappetite,andmoodchanges.</p></li><li><p>Specialcautioninbipolardisorder:antidepressantsmaytriggerorworsenmania;thus,useiscautiousandoftenavoidedunlesspairedwithamoodstabilizer.</p></li></ul></li><li><p>Otherantidepressants:</p><ul><li><p>Tricyclicantidepressants:fasteractionbuthigheroverdoseriskandmoresideeffects;usedwhenothermedicationsfail.</p></li><li><p>MAOinhibitors:rarelyusedduetodietaryrestrictionsandadverseinteractions;usedonlywhenotheroptionsfail.</p></li></ul></li><li><p>Ketamineandrelatednasal−spraytherapy:</p><ul><li><p>Ketamineisbeingstudied;publicperceptionisoftenoverstated;medicaluseremainsinearly−phaseevidencewithcontrolledtrials.</p></li><li><p>FDA−approvednasalsprayforseveresuicidalityexists(esketamine);evidencebaseisevolvingandusuallyusedinspecializedsettings.</p></li></ul></li><li><p>Bipolardisorderpharmacotherapy:</p><ul><li><p>AvoidSSRIs/SNRIsassolotreatmentsduetoriskoftriggeringmooddestabilization;moodstabilizersarecentral.</p></li><li><p>Moodstabilizersmostcommonlyincludelithium;alsoanticonvulsants(e.g.,gabapentin)andothermoodstabilizers.</p></li><li><p>Lithium:reducessuicideriskbuthasanarrowtherapeuticwindowandrequiresregularbloodmonitoring;potentialsideeffectsincludetremors,nausea,weightgain,andacne.</p></li><li><p>Anticonvulsants(anti−seizuremedications)canactasmoodstabilizers;gabapentinissometimesused,thoughitsmechanismformoodstabilizationisnotfullyunderstood.</p></li><li><p>Electroconvulsivetherapy(ECT):usedfortreatment−resistantdepression;modernECTissaferwithfewercognitivesideeffects,typically6–10outpatientsessions;risksincludeshort−termmemorylossandpotentialcognitiveeffects.</p></li></ul></li><li><p>Othermedicationconsiderations:</p><ul><li><p>Someneweroptions(e.g.,certainnasalsprays)targetsuicidalitymoredirectly,whileotherstargetunderlyingdepressivesymptoms.</p></li><li><p>Medicationchoicesmustconsiderhistoryofmanic/hypomanicepisodesandriskformooddestabilization.</p></li></ul></li></ul><h3id="d3d56d4b−0705−4f73−8037−9cf06ffca808"data−toc−id="d3d56d4b−0705−4f73−8037−9cf06ffca808"collapsed="false"seolevelmigrated="true">PsychotherapyAcrossMoodDisorders</h3><ul><li><p>CognitiveBehavioralTherapy(CBT):acentralevidence−basedapproach.</p><ul><li><p>Corefocus:thoughts,feelings,andbehaviors(thecognitive−behavioraltriangle).</p></li><li><p>Keycomponents:</p></li><li><p>Behavioralactivation:systematicallyincreaseengagementinmastery−andpleasure−buildingactivities.</p></li><li><p>Cognitiverestructuring:identifyandchallengenegativeautomaticthoughtsandcognitivedistortions;replacewithmorerealisticthoughts.</p></li><li><p>Thoughtrecords:weeklyorsession−basedrecordstotrackthoughts,emotions,andbehaviorsandidentifypatterns.</p></li></ul></li><li><p>Behavioralactivationandstepwisegoalsetting:</p><ul><li><p>Breaktasksintosmallsteps;scheduleactivitiestoimprovemoodandfunctioning;increasethelikelihoodofachievinggoals.</p></li></ul></li><li><p>Otherpsychotherapymodalities:</p><ul><li><p>AcceptanceandCommitmentTherapy(ACT)</p></li><li><p>DialecticalBehaviorTherapy(DBT)</p></li><li><p>Psychoanalytictherapy,emotion−focusedtherapy,andothers,chosenbasedonpatientneedsandtherapistexpertise.</p></li></ul></li><li><p>Forbipolardisorder:</p><ul><li><p>CBTisusedtoaddress:moodmonitoring,problem−solving,socialsupport,andreducingriskybehaviors.</p></li><li><p>Family−focusedtherapy:enhancessocialsupportandmedicationadherence;reducesconflictandimprovescommunication.</p></li><li><p>Interpersonalandsocialrhythmtherapy(ISRT):stabilizesdailyroutinesandsleep/wakecycles;leveragesenvironmentalcuestoregulatemood.</p></li><li><p>Moodmonitoringandself−monitoringcharts:helptrackmood,sleep,anxiety,irritability,energy,substanceuse,self−harm,suicidality,andfunctioning.</p></li><li><p>TheMoodMonitoringChartexampleillustrates:moodcontinuum,sleephours,anxiety,irritability,weight,medicationadherence,workimpact,socialconnections,andriskybehaviors;usedtoidentifypatternsandguideinterventions.</p></li></ul></li></ul><h3id="9c58b5e4−f887−44ab−8910−a8ec0049c402"data−toc−id="9c58b5e4−f887−44ab−8910−a8ec0049c402"collapsed="false"seolevelmigrated="true">Suicidality:Definitions,Theories,andRiskManagement</h3><ul><li><p>Keyterms:</p><ul><li><p>Suicide:deathcausedbyself−directedinjuriousbehaviorwithintenttodie.</p></li><li><p>Nonsuicidalself−injury(NSSI):self−directedinjurywithouttheintenttodie.</p></li><li><p>Suicidalideation:thoughtsaboutsuicide,whichmayincludeaplanorintent.</p></li><li><p>Diebysuicide:alternativetermforsuicidethatavoidsstigmatizingconnotationsof“committingsuicide.”</p></li></ul></li><li><p>Demographicandepidemiologiccontext:</p><ul><li><p>Suicideisthe11thleadingcauseofdeathoverall;itisthesecondleadingcauseofdeathamongages10–34.</p></li><li><p>Leadingcausesofdeathforyoungeragegroupsshifttowardunintentionalinjuries,suicide,andhomicidedependingonage;race/ethnicitydifferencesinfluencecompletedsuicideratesandaccesstomeans.</p></li><li><p>CompletedsuicideismorecommoninWhite/CaucasianandNativeAmericanpopulations;ratesvarybygroupandcontext.</p></li><li><p>Genderdifferences:mendiebysuicidemoreoften(oftenviamorelethalmeans),whilewomenattemptsuicidemorefrequently.</p></li></ul></li><li><p>Theoriesofsuiciderisk:</p><ul><li><p>Interpersonaltheoryofsuicide:</p></li><li><p>Thwartedbelongingness:feelingsoflonelinessandlackofbelonging.</p></li><li><p>Perceivedburdensomeness:beliefsthatoneisaburdentoothers.</p></li><li><p>Capabilityforsuicide:increasedcapabilityduetoaccesstomeansorpriorexposuretopainfulexperiences;thecombinationincreasesdesireandcapabilityforsuicide.</p></li><li><p>Aprotectivefactorexistswhenatleastoneacceptingadultrelationshipispresent;evenonesupportiveadultcansignificantlyreduceriskforLGBTQ+youth.</p></li><li><p>Three−steptheoryofsuicide(conceptualframework):</p></li><li><p>Painandhopelessnessleadtosuicidalideationwhenconnectednessisinsufficient;capabilitydeterminesprogressionfromideationtoattempt.</p></li><li><p>Accesstolethalmeansasamajorriskfactor(e.g.,firearms).</p></li></ul></li><li><p>Riskfactorsandprotectivefactors:</p><ul><li><p>Riskfactors:priorsuicideattempts,familyhistoryofsuicide,stressful/luminallifeevents,alcoholorsubstanceuse,poorsocialsupport,imminentaccesstomeans,andchronicpain.</p></li><li><p>Protectivefactors:strongsocialsupport,accesstocare,copingskills,reasonsforliving(lovedones,futuregoals,pets).</p></li></ul></li><li><p>Riskassessmentandintervention:</p><ul><li><p>Suicideriskassessmentscannotperfectlypredictwhowilldiebysuicide,buttheyarevaluableforbuildingconnection,planningtreatment,andidentifyingsafetysteps.</p></li><li><p>Safetyplanningandmeansrestrictionareessentialcomponentsofintervention.</p></li><li><p>Interventionsincludeidentifyingreasonsforliving,balancingtheclient’sgoalswithsafetyneeds,andengagingfamilyandfriendstosupportsafetyplanning.</p></li><li><p>Practicalsafetystrategiestoslowaccessincludesecurestorageoffirearms,removingordelayingaccesstomeans(e.g.,medsinacaroratafriend’shouse,freezingmedications).</p></li></ul></li><li><p>Specialpopulationconsiderations:</p><ul><li><p>LGBTQ+youthfacehigherriskofsuicidalityduetodiscriminationandlackofbelonging;protectivefactorsincludeatleastoneacceptingadultrelationship.</p></li><li><p>Culturalandreligiousfactorscaninfluencesuicidalityandhelp−seekingbehaviors.</p></li></ul></li></ul><h3id="7a9af17e−fe81−4dac−8b7e−978223f4c9d1"data−toc−id="7a9af17e−fe81−4dac−8b7e−978223f4c9d1"collapsed="false"seolevelmigrated="true">TreatingMoodDisorders:PracticalConsiderations</h3><ul><li><p>Generaltreatmentplanning:</p><ul><li><p>Thecourseofmooddisorderscanbechronicorepisodic;treatmentaimstoreducesymptoms,preventrelapse,andhelpthepersonfunctionandenjoylife.</p></li><li><p>Thechoicebetweenmedicationandtherapyisindividualized;manyindividualsbenefitfromacombination.</p></li><li><p>Long−termmaintenance:sustainedlearningofcopingskillsandrelapsepreventionstrategieswiththerapycanbeessential,evenwhenmedicationsarehelpful.</p></li></ul></li><li><p>Safetyandassessmentintreatment:</p><ul><li><p>Safetyplansandongoingriskassessmentareessential,especiallywhensuicidalityispresentorriskfactorsareidentified.</p></li><li><p>Cliniciansshouldcoordinatewithfamilymembersorsupportnetworkstohelpmonitorandreinforcetreatmentgoals.</p></li></ul></li></ul><h3id="6d969fd3−9689−4acc−b7a6−aabf7302f051"data−toc−id="6d969fd3−9689−4acc−b7a6−aabf7302f051"collapsed="false"seolevelmigrated="true">QuickReference:KeyCriteriaandNumbers</h3><ul><li><p>Majordepressiveepisode(MDE)duration:atleast.</p></li><li><p>Side effects vary by medication and individual; possible effects include sleep disturbances, nausea, headaches, changes in appetite, and mood changes.</p></li><li><p>Special caution in bipolar disorder: antidepressants may trigger or worsen mania; thus, use is cautious and often avoided unless paired with a mood stabilizer.</p></li></ul></li><li><p>Other antidepressants:</p><ul><li><p>Tricyclic antidepressants: faster action but higher overdose risk and more side effects; used when other medications fail.</p></li><li><p>MAO inhibitors: rarely used due to dietary restrictions and adverse interactions; used only when other options fail.</p></li></ul></li><li><p>Ketamine and related nasal-spray therapy:</p><ul><li><p>Ketamine is being studied; public perception is often overstated; medical use remains in early-phase evidence with controlled trials.</p></li><li><p>FDA-approved nasal spray for severe suicidality exists (esketamine); evidence base is evolving and usually used in specialized settings.</p></li></ul></li><li><p>Bipolar disorder pharmacotherapy:</p><ul><li><p>Avoid SSRIs/SNRIs as solo treatments due to risk of triggering mood destabilization; mood stabilizers are central.</p></li><li><p>Mood stabilizers most commonly include lithium; also anticonvulsants (e.g., gabapentin) and other mood stabilizers.</p></li><li><p>Lithium: reduces suicide risk but has a narrow therapeutic window and requires regular blood monitoring; potential side effects include tremors, nausea, weight gain, and acne.</p></li><li><p>Anticonvulsants (anti-seizure medications) can act as mood stabilizers; gabapentin is sometimes used, though its mechanism for mood stabilization is not fully understood.</p></li><li><p>Electroconvulsive therapy (ECT): used for treatment-resistant depression; modern ECT is safer with fewer cognitive side effects, typically 6–10 outpatient sessions; risks include short-term memory loss and potential cognitive effects.</p></li></ul></li><li><p>Other medication considerations:</p><ul><li><p>Some newer options (e.g., certain nasal sprays) target suicidality more directly, while others target underlying depressive symptoms.</p></li><li><p>Medication choices must consider history of manic/hypomanic episodes and risk for mood destabilization.</p></li></ul></li></ul><h3 id="d3d56d4b-0705-4f73-8037-9cf06ffca808" data-toc-id="d3d56d4b-0705-4f73-8037-9cf06ffca808" collapsed="false" seolevelmigrated="true">Psychotherapy Across Mood Disorders</h3><ul><li><p>Cognitive Behavioral Therapy (CBT): a central evidence-based approach.</p><ul><li><p>Core focus: thoughts, feelings, and behaviors (the cognitive-behavioral triangle).</p></li><li><p>Key components:</p></li><li><p>Behavioral activation: systematically increase engagement in mastery- and pleasure-building activities.</p></li><li><p>Cognitive restructuring: identify and challenge negative automatic thoughts and cognitive distortions; replace with more realistic thoughts.</p></li><li><p>Thought records: weekly or session-based records to track thoughts, emotions, and behaviors and identify patterns.</p></li></ul></li><li><p>Behavioral activation and stepwise goal setting:</p><ul><li><p>Break tasks into small steps; schedule activities to improve mood and functioning; increase the likelihood of achieving goals.</p></li></ul></li><li><p>Other psychotherapy modalities:</p><ul><li><p>Acceptance and Commitment Therapy (ACT)</p></li><li><p>Dialectical Behavior Therapy (DBT)</p></li><li><p>Psychoanalytic therapy, emotion-focused therapy, and others, chosen based on patient needs and therapist expertise.</p></li></ul></li><li><p>For bipolar disorder:</p><ul><li><p>CBT is used to address: mood monitoring, problem-solving, social support, and reducing risky behaviors.</p></li><li><p>Family-focused therapy: enhances social support and medication adherence; reduces conflict and improves communication.</p></li><li><p>Interpersonal and social rhythm therapy (ISRT): stabilizes daily routines and sleep/wake cycles; leverages environmental cues to regulate mood.</p></li><li><p>Mood monitoring and self-monitoring charts: help track mood, sleep, anxiety, irritability, energy, substance use, self-harm, suicidality, and functioning.</p></li><li><p>The Mood Monitoring Chart example illustrates: mood continuum, sleep hours, anxiety, irritability, weight, medication adherence, work impact, social connections, and risky behaviors; used to identify patterns and guide interventions.</p></li></ul></li></ul><h3 id="9c58b5e4-f887-44ab-8910-a8ec0049c402" data-toc-id="9c58b5e4-f887-44ab-8910-a8ec0049c402" collapsed="false" seolevelmigrated="true">Suicidality: Definitions, Theories, and Risk Management</h3><ul><li><p>Key terms:</p><ul><li><p>Suicide: death caused by self-directed injurious behavior with intent to die.</p></li><li><p>Nonsuicidal self-injury (NSSI): self-directed injury without the intent to die.</p></li><li><p>Suicidal ideation: thoughts about suicide, which may include a plan or intent.</p></li><li><p>Die by suicide: alternative term for suicide that avoids stigmatizing connotations of “committing suicide.”</p></li></ul></li><li><p>Demographic and epidemiologic context:</p><ul><li><p>Suicide is the 11th leading cause of death overall; it is the second leading cause of death among ages 10–34.</p></li><li><p>Leading causes of death for younger age groups shift toward unintentional injuries, suicide, and homicide depending on age; race/ethnicity differences influence completed suicide rates and access to means.</p></li><li><p>Completed suicide is more common in White/Caucasian and Native American populations; rates vary by group and context.</p></li><li><p>Gender differences: men die by suicide more often (often via more lethal means), while women attempt suicide more frequently.</p></li></ul></li><li><p>Theories of suicide risk:</p><ul><li><p>Interpersonal theory of suicide:</p></li><li><p>Thwarted belongingness: feelings of loneliness and lack of belonging.</p></li><li><p>Perceived burdensomeness: beliefs that one is a burden to others.</p></li><li><p>Capability for suicide: increased capability due to access to means or prior exposure to painful experiences; the combination increases desire and capability for suicide.</p></li><li><p>A protective factor exists when at least one accepting adult relationship is present; even one supportive adult can significantly reduce risk for LGBTQ+ youth.</p></li><li><p>Three-step theory of suicide (conceptual framework):</p></li><li><p>Pain and hopelessness lead to suicidal ideation when connectedness is insufficient; capability determines progression from ideation to attempt.</p></li><li><p>Access to lethal means as a major risk factor (e.g., firearms).</p></li></ul></li><li><p>Risk factors and protective factors:</p><ul><li><p>Risk factors: prior suicide attempts, family history of suicide, stressful/luminal life events, alcohol or substance use, poor social support, imminent access to means, and chronic pain.</p></li><li><p>Protective factors: strong social support, access to care, coping skills, reasons for living (loved ones, future goals, pets).</p></li></ul></li><li><p>Risk assessment and intervention:</p><ul><li><p>Suicide risk assessments cannot perfectly predict who will die by suicide, but they are valuable for building connection, planning treatment, and identifying safety steps.</p></li><li><p>Safety planning and means restriction are essential components of intervention.</p></li><li><p>Interventions include identifying reasons for living, balancing the client’s goals with safety needs, and engaging family and friends to support safety planning.</p></li><li><p>Practical safety strategies to slow access include secure storage of firearms, removing or delaying access to means (e.g., meds in a car or at a friend’s house, freezing medications).</p></li></ul></li><li><p>Special population considerations:</p><ul><li><p>LGBTQ+ youth face higher risk of suicidality due to discrimination and lack of belonging; protective factors include at least one accepting adult relationship.</p></li><li><p>Cultural and religious factors can influence suicidality and help-seeking behaviors.</p></li></ul></li></ul><h3 id="7a9af17e-fe81-4dac-8b7e-978223f4c9d1" data-toc-id="7a9af17e-fe81-4dac-8b7e-978223f4c9d1" collapsed="false" seolevelmigrated="true">Treating Mood Disorders: Practical Considerations</h3><ul><li><p>General treatment planning:</p><ul><li><p>The course of mood disorders can be chronic or episodic; treatment aims to reduce symptoms, prevent relapse, and help the person function and enjoy life.</p></li><li><p>The choice between medication and therapy is individualized; many individuals benefit from a combination.</p></li><li><p>Long-term maintenance: sustained learning of coping skills and relapse prevention strategies with therapy can be essential, even when medications are helpful.</p></li></ul></li><li><p>Safety and assessment in treatment:</p><ul><li><p>Safety plans and ongoing risk assessment are essential, especially when suicidality is present or risk factors are identified.</p></li><li><p>Clinicians should coordinate with family members or support networks to help monitor and reinforce treatment goals.</p></li></ul></li></ul><h3 id="6d969fd3-9689-4acc-b7a6-aabf7302f051" data-toc-id="6d969fd3-9689-4acc-b7a6-aabf7302f051" collapsed="false" seolevelmigrated="true">Quick Reference: Key Criteria and Numbers</h3><ul><li><p>Major depressive episode (MDE) duration: at least2\text{ weeks}.</p></li><li><p>MDEsymptomcount:atleast.</p></li><li><p>MDE symptom count: at least5/9 symptoms, with at least one of the core symptoms (1) depressed mood or (2) anhedonia.

    • Depressive disorders spectrum:

      • Major depressive disorder (MDD): at least one MDE; impairment; no mania/hypomania; specifiers:

      • with psychotic features, anxious distress, mixed features, catatonic, peripartum, seasonal pattern.

      • Persistent depressive disorder (PDD): depressed mood most of the day for >2\ years;atleasttwoofthefollowing;nomanic/hypomanicepisodesorcyclothymicdisorder.</p></li></ul></li><li><p>Bipolarspectrum:</p><ul><li><p>Manicepisode:; at least two of the following; no manic/hypomanic episodes or cyclothymic disorder.</p></li></ul></li><li><p>Bipolar spectrum:</p><ul><li><p>Manic episode: ext{duration} \ge 1\text{ week};3of7symptoms(4ifirritablemood)withmarkedimpairment.</p></li><li><p>Hypomanicepisode:; 3 of 7 symptoms (4 if irritable mood) with marked impairment.</p></li><li><p>Hypomanic episode:\ge 4\ days;3of7symptoms;nomarkedimpairment;nopsychoticfeatures(ifpsychoticfeaturespresent,manicepisode).</p></li><li><p>BipolarI:includesmanicepisodes;depressiveepisodesmayoccur.</p></li><li><p>BipolarII:majordepressiveepisodeswithhypomanicepisodes;nofullmania.</p></li><li><p>Cyclothymicdisorder:moodswingsbetweenhypomanicandmilddepressiveperiodsforatleast; 3 of 7 symptoms; no marked impairment; no psychotic features (if psychotic features present, manic episode).</p></li><li><p>Bipolar I: includes manic episodes; depressive episodes may occur.</p></li><li><p>Bipolar II: major depressive episodes with hypomanic episodes; no full mania.</p></li><li><p>Cyclothymic disorder: mood swings between hypomanic and mild depressive periods for at least2\ years;notmeetingfullMDE/maniacriteria;nomorethan2monthswithoutsymptoms.</p></li><li><p>Rapidcycling:; not meeting full MDE/mania criteria; no more than 2 months without symptoms.</p></li><li><p>Rapid cycling:\ge 4\text{ mood episodes in 1 year};oftenindicateshigherseverityandtreatmentchallenge.</p></li></ul></li><li><p>Epidemiology:</p><ul><li><p>MDDlifetime:; often indicates higher severity and treatment challenge.</p></li></ul></li><li><p>Epidemiology:</p><ul><li><p>MDD lifetime:16\%;annual:; annual:6\%.</p></li><li><p>Bipolarlifetimeprevalence:.</p></li><li><p>Bipolar lifetime prevalence:\approx 1\%.</p></li><li><p>Suicideriskinmooddisorders:lifetimesuicideattempts.</p></li><li><p>Suicide risk in mood disorders: lifetime suicide attempts12\% \text{ to } 48\%;deathbysuicideriskmarkedlyhigherthangeneralpopulation;roughly; death by suicide risk markedly higher than general population; roughly\approx 20\times$$ higher.

    • Etiology (summary): biology, genetics, neurotransmitters, endocrine (HPA axis), neurogenesis, cognitive and behavioral factors, and social/cultural contexts.

    • Treatments (summary): medications (SSRIs/SNRIs, mood stabilizers like lithium, anticonvulsants such as gabapentin, MAO inhibitors, rarely TCAs; ketamine/esketamine for suicidality), psychotherapy (CBT and related approaches, ISRT, family-focused therapy, behavioral activation, cognitive restructuring), ECT for treatment-resistant depression, safety planning and risk management, and social/environmental interventions to enhance social support and routines.

    Closing Notes

    • Mood disorders involve a complex interplay of biological, psychological, and social factors; no single cause explains all cases.

    • Accurate diagnosis depends on longitudinal history and careful evaluation of past mood episodes (especially mania/hypomania) in addition to current mood symptoms.

    • Treatment is individualized and often multimodal; ongoing monitoring, safety planning, and psychoeducation are essential for effective management.

    • If you or someone you know is at risk of suicide or self-harm, seek immediate professional help and contact local emergency services or crisis lines.