Chapter 7: Mood Disorders and Suicide

Understanding and Defining Mood Disorders

• Mood disorders = psychological conditions marked by gross deviations in mood
• Two fundamental mood states
  • Major Depressive Episode (MDE)
  • ≥ 2 weeks of extreme depressed mood
  • Central indicators:
    • \text{somatic (vegetative) symptoms: sleep↑⁄↓, appetite↑⁄↓, weight↑⁄↓, energy↓
    • Anhedonia = inability to experience pleasure
  • DSM-5 Criteria (Table 7.1)
    • 5⁺ of 9 symptoms, incl. depressed mood OR loss of interest/pleasure
    • Clinically significant distress/impairment; not due to substance/medical condition
  • Untreated duration: 4\text{–}9\text{ months}
  • Manic Episode
  • ≥ 1 week (or hospitalization) of abnormally elevated/irritable mood + ↑goal-directed activity/energy
  • Symptoms (3⁺; 4⁺ if mood only irritable): grandiosity, ↓sleep need, pressured speech, flight of ideas, distractibility, ↑goal-directed acts or psychomotor agitation, risky behaviors
  • Untreated duration: 3\text{–}4\text{ months}
  • Hypomanic Episode
  • Same symptoms as mania but ≥ 4 days, no marked impairment/hospitalization
  • Mixed Features
  • Simultaneous presence of depressive + manic symptoms

Structure & Classification (DSM-5)

• Unipolar Disorders: only depression or mania (mania alone rare)
• Bipolar Disorders: alternation of depression & mania/hypomania
• Course specifiers: single vs. recurrent; full vs. partial remission; rapid cycling (≥4 episodes/yr)

Depressive Disorders

• Major Depressive Disorder (MDD)
  • Presence of one or more MDEs, no mania/hypomania
  • Recurrent if ≥ 2 episodes separated by ≥ 2 months
  • Median episodes: 4–7; median duration 4–5 months
• Persistent Depressive Disorder (PDD / Dysthymia)
  • Depressed mood ≥ 2 years (1 yr youth); symptom-free ≤ 2 mo.
  • Types:
  • Pure dysthymic syndrome (no MDE x 2 yr)
  • Persistent major depressive episode (full MDE ≥ 2 yr)
  • Intermittent MDEs ("double depression")
  • Higher comorbidity, poorer treatment response; relapse ≈ 71 %
• Premenstrual Dysphoric Disorder (PMDD)
  • 2–5 % of women; 5⁺ affective/somatic symptoms final week pre-menses, remit post-menses
• Disruptive Mood Dysregulation Disorder (DMDD)
  • Children ≤ 12 yrs; severe temper outbursts 3⁺/wk, persistent irritability ≥ 12 mo., no mania

Depressive Specifiers (8)

1. Psychotic features (mood-congruent/incongruent)
2. Anxious distress
3. Mixed features
4. Melancholic
5. Atypical (hypersomnia, hyperphagia, mood reactivity)
6. Catatonic
7. Peripartum onset (pregnancy → 6 mo postpartum)
8. Seasonal pattern (SAD)

Bipolar Disorders

• Bipolar I: at least one manic episode; MDE common but not required
• Bipolar II: ≥ 1 MDE + ≥ 1 hypomanic episode; no mania
• Cyclothymic Disorder: ≥ 2 yrs (1 yr youth) of numerous hypomanic & mild depressive periods; no full episodes
• Rapid Cycling Specifier: ≥ 4 mood episodes/yr; 60–90 % female; poorer prognosis
• Onset: BP I 15–18 yrs; BP II 19–22 yrs; rare after 40
• Suicide risk high; untreated course chronic

Prevalence & Development

• Lifetime: MDD ≈ 16 %; PDD ≈ 3.5 %; Bipolar ≈ 1 %
• Gender: women 2 × men for MDD/PDD; equal in bipolar
• Childhood: MDD 1–2 %; rises sharply in adolescence (♀ > ♂)
• Elderly: lower MDD prevalence but higher dysthymia; comorbid medical illness complicates dx
• Culture: somatic presentations common; SAD higher at high latitudes; Chinese rates lower, Native American higher
• Creativity link: ↑bipolar traits among poets/artists (≈ 20 %)

Etiology – Integrative Model

Biological Dimensions

• Genetics: heritability ≈ 40 % women, 20 % men for MDD; higher for bipolar
  • Shared genetic diathesis with anxiety (neuroticism)
• Neurotransmitters: “permissive hypothesis” – ↓serotonin allows dysregulation of NE & DA; dopamine ↑ in mania
• Endocrine: HPA-axis hyperactivity, ↑cortisol; DST nonsuppression; ↓hippocampal neurogenesis
• Sleep: ↓REM latency, ↑REM intensity, ↓slow-wave sleep; phase shift in SAD
• Brain circuits: ↓L-PFC, ↑R-PFC; altered anterior cingulate, amygdala

Psychological Dimensions

• Stressful life events: humiliation, loss, social rejection → MDD; goal-attainment events & circadian disruption → mania
• Learned Helplessness (Seligman): internal, stable, global attributions → hopelessness
• Beck’s Cognitive Errors: arbitrary inference, overgeneralization; depressive cognitive triad (self–world–future)

Social & Cultural Dimensions

• Marital discord: depression ↔ marital problems; separation increases male depression risk
• Gender roles: socialization, rumination in women
• Social support buffers onset & facilitates recovery; isolation increases risk

Treatments for Depression

Pharmacotherapy

• SSRIs (fluoxetine, sertraline), SNRIs (venlafaxine), Tricyclics (imipramine), MAO-Is (phenelzine)
  • Response ≈ 50 %; remission 25–30 %; severe depression benefits most
• Atypicals: bupropion; adjuncts
• Continuation 6–12 mo post-episode; maintenance for recurrent/chronic

Lithium & Mood Stabilizers

• Lithium carbonate: gold-standard for bipolar; ↓suicide risk
• Anticonvulsants (valproate) for rapid cycling; antipsychotics for acute mania

Somatic Treatments

• Electroconvulsive Therapy (ECT): 6–10 sessions; > 50 % response in severe/psychotic MDD; memory side-effects
• Transcranial Magnetic Stimulation (TMS); Vagus Nerve Stimulation; Deep Brain Stimulation (experimental)

Psychotherapy

• Cognitive Therapy (Beck): identify & modify automatic negative thoughts; behavioral activation; mindfulness-based CBT
• Behavioral Activation: scheduling pleasurable/mastery activities, exercise
• Interpersonal Psychotherapy (IPT): resolve role disputes, role transitions, grief, interpersonal deficits
• CBT & IPT efficacy = meds; CBT protective against relapse; combination > monotherapy in chronic MDD

Prevention & Maintenance

• Continuation CBT, mindfulness, and IPSRT reduce relapse
• Prevention programs (CBT skills) effective in at-risk adolescents & families

Treatments for Bipolar Disorder

• Pharmacotherapy mandatory (mood stabilizer)
• Psychosocial adjuncts
  • Interpersonal & Social Rhythm Therapy (IPSRT): regulate sleep/ routines
  • Family-Focused Therapy (FFT): psychoeducation, communication, problem-solving → ↓relapse (35 % vs 54 %)
  • CBT for medication adherence, coping skills; useful for depressive phase/rapid cycling

Suicide

Statistics

• 11th US cause of death (~40 k/yr); worldwide ~1 M/yr
• Gender paradox: attempts ♀ > ♂; completions ♂ 4 × ♀ (except China)
• Peak risk: adolescents & elderly; Native Americans highest US rate

Risk Factors

• Family history & genetics (serotonin, impulsivity)
• Neurobiology: ↓5-HIAA; stress response
• Psychological: mood disorders (esp. MDD, bipolar), substance abuse, borderline PD, hopelessness, impulsivity
• Precipitants: shame/humiliation, loss, chronic pain, abuse, catastrophic illness, natural disasters
• Prior attempt = strongest predictor
• Contagion: media reports, peer suicides, clusters

Assessment & Intervention

• Evaluate suicidal desire, capability, intent (plans, means)
• Safety planning, no-suicide contracts, lethal-means restriction
• Acute treatment: hospitalization if necessary; CBT for suicide prevention (10 sessions ↓re-attempts 50 %)
• Address underlying disorders: meds, psychotherapy; enhance social support
• Public health: hotline, screening, postvention after suicide, media guidelines