Module 3 - Mood Disorders and Suicide Flashcards
Humoral Theory to mental disorders
proposed that “exhaltation” (mania) was caused by an excess of warmth and dampness in the brain and that melancholia (depression) was caused by an excess of black bile, which could be seen as heavy residue in the blood or discolorations in the skin. Therefore, bloodletting was attempted to cure melancholia.
The first to suggest psychotherapy as a treatment for melancholia
Cicero
How do we diagnose mood disorders?
To meet the DSM-5-TR criteria for a mood disorder several symptoms must co-occur
Therefore it is only when multiple symptoms co-occur and meet stringent criteria for duration and severity that a mood disorder is present
What are the major theories of the etiology of mood disorders? And some of the key mechanisms that have been suggested in those theories
Cognitve-behavioural
Biological
What are key risks for suicide?
1 cause of suicide is untreated mental health disorder
Strongest risk factor is being a man. 3x more likely than a woman.
Men aged 19-24 and over age 70 at greatest age group risk
Ppl who identify as lesbian, gay, bi, trans, two-spirit, queer/questioning, 5x higher than non LGBTQ+2S
Hihest rates are found in Eastern Europe, Russia, South Korea, and Japan
Indigenous 3x higher
Depression is present in at least half of suicides
Low levels of serotonin have been implictaed in suicide
How has the mental health community approached the critical issue of suicide?
Prevent Suicide in Canada framework:
1) provide guidelines to improve public awareness and knowledge of suicide
2) disseminate information about suicide and its prevention
3) make existing statistics about suicide and related risk factors publicly available
4) promote collaboration and knowledge exchange across, domains, sectors, regions, and jurisdictions
5) Define best practices for suicide prevention
6) promote the use of research and evidence based practices for suicide prevention
Most effective primary strategy is to restrict access to suicide means
Secondary/Tertiary is training primary care physicians to recognize, screen and respond to suicidal ideation and behaviour
Time frame and key diagnostic features of Bipolar I
One or more manic episodes with or without one or more major depressive disorders
A depressive episode is NOT required for diagnosis of BPI
Manic episodes Typically lasts between 2 weeks and 4 months
Depressive episodes last between 6-9 months
Time frame and key diagnostic features of Bipolar II
One or more hypomanic episodes with one or more major depressive episodes.
Can be more difficult to diagnose b/c hypomanic episodes are not as severe as manic
Hypomanic episode may be experienced as a period of successful high productivity
Hypomanic episodes Typically lasts between 2 weeks and 4 months
Depressive episodes last between 6-9 months
An altered state severe enough to interfere with a person’s social and occupational functioning, and who’s range of symptoms is not limited to the persons feelings, but affects other bodily and behavioural systems as well.
Mood Disorder
Imagined Loss
A fruedian theory that the individual unconsciously interprets all types of loss events (i.e., job loss) in terms of grief, thereby raising the risk of depression.
DSM-5-TR criteria for Major Depressive Disorder
Symptoms must be present for most of the day
More days than not
For at least two weeks (duration)
Include 9 symptoms, 5 which must be present to achieve diagnosis.
Difficulties falling asleep (more than one hour to fall asleep = severity)
How are mood disorders in the DSM-5-TR classified?
Into two broad categories: unipolar and bipolar
Depressive Disorders
Mood disorders in which the change in mood is only in the direction of depression, or lowered mood, followed by a return to normal mood with recovery. (Unipolar)
Bipolar and related disorders
Mood disorders in which the change in mood is in both directions; that is the patient sometimes experiences depression and other time mania.
Growing consensus that onset can occur in childhood. However, children with bipolar often do not meet the DSM-5-TR definition and tend to have rapid-cycling or mixed cycling patterns.
Types of Depressive Disorders
Major Depressive Disorder (MDD)
Persistent Depressive Disorder
Bipolar mood disorders (Bipolar I and Bipolar II)
Cyclothymia
Rapid Cycling Specifier
Mood disorder with seasonal Pattern
Mood disorder with Peri or Postpartum onset
Premenstrual Dysphoric Disorder
MDD
Major Depressive Disorder:
Common cold bc so prevalent
Costs Canadian economy 32.3 billion a year
Involves biological, emotional, cognitive, and behavioural changes
Approx 50% of individuals who have one episode of depression will have a second. Up to 90% who experience 2 episodes will experience 3
Average age of first onset is early to mid 20’s
Episodes themselves last between 6-9 months. Although they can last for years
Individuals with MDD often suffer one or more mental health disorders, most common class of comorbid with MDD is anxiety disorders, affecting more then 50% of patients with MDD
Women and indigenous men 2x the prevelance rate
Diagnostic criteria for MDD
A. 5 or more of the following symptoms must be present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.
- Depressed mood most of the day, nearly everyday (subjective report or observation)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss when not dieting or weight gain (change of more than 5% body weight in a month), or decrease or increase in appetite nearly every day.
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day (observable, not merely subjective feelings of being run down or being slowed down).
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (subjective account or observation by others)
- Recurrent thoughts of death (not just fear of dying). recurrent suicidal ideation without a specific plan, or a suicide attempt, or a specific plan
B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
Persistent Depressive Disorder
A depressed mood for most of the day, more days than not, lasting for at least 2 years, along with at least 3 out of 6 additional symptoms
Appetite disturbance
Sleep disturbance
low energy
low self-esteem
poor concentration
difficulty making decisions
hopelesssness
Many with Persistent Depressive disorder also experience recurrent periods of MDD.
Another presentation is persistent major depression (full criteria for MDD has been met for the last 2 years)
In all manifestations, persistent depression has higher levels of impairment, a younger age of onset, higher rates of comorbidity, a stronger family history of psychiatric disorder, lower levels of social support, higher levels of stress and higher levels of dysfunctional personality traits than does episodic major depression. Also less likely to respond to treatment
Mania
Distinct period of elevated, irritable or expansive mood that lasts at least one week and is accompanied by at least 3 associated symptoms.
Symptoms include:
Increased energy
Decreased need for sleep
racing thoughts
pressured speech
problems with attention and concentration
Judgement is also impaired (shopping, sex, aggression)
May feel that they are special in some way
Diagnostic Criteria for manic episode
A. A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently goal-directed activity or energy, lasting at least one week and present most of the day, nearly everyday.
B. During the period of mood disturbance and increased energy or activity, 3 or more of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticable change in usual behaviour:
- Inflated self-esteem/grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractability
- Increase in goal-directed activity
- Excessive involvement in activities that have high potential for painful consequences
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or if there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance
hypomania
less severe form of mania that involves a similar number of symptoms, but those symptoms only need to be present for 4 days
Cyclothymia
Chronic, but less severe form of bipolar disorder
History of at least 2 years of alternating hypomanic and depressive episodes that do not meet the full criteria for MDD.
Mood swings are relatively mild but individuals with this are at risk for full blown bipolar
Antidepressants should be used with caution with this group as these medications can trigger manic episodes in vulnerable patients.
Rapid Cycling Specifier
Presence of 4 or more manic and/or major depressive episodes in a 12 month period
The episodes must be separated from each other by at least two months of full or partial remission, or by a switch to the opposite mood state.
Ppl with this have higher rates of disability and lower rates of response to treatment
Rapid cycling can be induced or made worse by antidepressant medications. So if they are taking antidepressants they will also need to take a mood stabilizer (lithim)
Ultrarapid = cycling every few days
Ultradian= cycling daily
Seasonal Affective Disorder (SAD)
Can occur in both unipolar MDD and bipolar disorder and is characterized by recurrent depressive episodes that are tied to the changing seasons
Likely more to the story than melatonin dysregulation alone
Evidence suggests phase-delayed circadian ryhtym
Vitamin D supplementation before winter may prevent the emergence of SAD (vit D related to serotonin activity)
Mood disorder with Peri (last month of gestation) or Postpartum onset
As many as 70% of women who give birth experience mood swings and feelings of depression up to two weeks after child birth.
in most, symptoms resolve themselves. In others, mood swings are chronic and severe enough to meet criteria for MDD. In very rare cases, psychotic episodes
Postpartum has a 5% suicide rate and 4% infantcide rate.
Rates are significantly higher in countries with higher levels of income inequality, maternal or infant mortality, or child-bearing age women working more than 40 hours per week
Significantly higher in immigrant and indigenous women (greater level of exposure to risk factors of lower income, low education, low social support, etc)
Greatest risk factors include:
History of previous depressive episodes
Severely stressful life events concurrent with, or immediately following childbirth (divorce, eviction)
Poor marital relationship
Low support from partner
Biological factors:
sensitive to rapid changes in reproductive hormones that occur at delivery
Associated with issues of child development - slowed language development, stunted growth
Premenstrual Dysphoric Disorder (PMDD)
marked affective lability, irritability/anger, depressed mood, and/or anxiety.
plus the presence of additional symptoms of loss of interest in activities, concentration difficulties, low energy, changes in appetite and/or sleep, feelings of loss of control, and/or phsyical symptoms.
5 symptoms must be present for DSM-5 criteria, and these symptoms must significantly interfere with daily functioning.
These symptoms must be present for most menstrual cycles in the past year
Psychological and Environmental Causal Factors of mood disorders
Psychological -
-Personality theories
-Cognitive theories
-Interpersonal models
Environmental -
-Life stress perspective
-Childhood stressful life events
Biological causal factors of mood disorders
Genetics
Neurotransmitters
Stress and the Hypothalamic-pituitary-adrenal axis
Etiology of mood disorders
No single cause and these disorders are likely cause by an interaction of a number of risk factors at a number of levels of analysis.
Ex: mood disorders are highly heritable but a family history does not guarantee presence of disorder.
Personality theories of mood disorders
Personality models:
1) 5 factor model
2) Behavioural inhibition system/behavioural activation system (BIS/BAS)
5 factor model of personality
5 factor model of personality - openness to experience, conscientiousness, extraversion, agreeableness, neuroticism
Neuroticism = depression, anxiety, high stress reactivity (strongly depression)
Extraversion = depression significantly associated with low levels of extraversion.
Conscientiousness = depression significantly associated with low levels
High Extraversion and high openness to experience most associated with bipolar
Behavioural inhibition system/behavioural activation system (BIS/BAS)
Relates two primary personality features with their underlying brain systems.
-BIS is the punishment system and regulates avoidance behaviours.
Ppl high on BIS more fearful of novelty and uncertainty, more sensitive to punishment, more likely to display negative emotional states such as depression and anxiety and frustration.
-BAS is the reward system and regulates approach behaviours.
Ppl high in BAS are more impulsive and have more difficulty regulating their emotions and inhibiting their behaviour, when faced with rewarding stimuli.
Bipolar
Cognitive theories of mood disorders
Diathesis stress model
Cognitive distortions
Thoughts about self, world or future that are distortions of the true state of affairs.
In particular ppl who are depressed apply cognitive distortions, most common are:
1) all or nothing thinking
2) Overgeneralization
3) Magnification/Catastrophizing
4) Jumping to conclusions
Interpersonal models
stress generation hypothesis
interpersonal model of depression
Behaviours:
Excessive reassurance seeking
Negative feedback seeking
Stress generation hypothesis
A theory of depression recurrence stating that individuals with a history of depression have higher rates of stressful life events that are at least in part dependent on their own behavour or characteristics than non-depressed people.
They generate stressful life events like fights, arguments, interpersonal rejection
Life Stress perspective
For a significant minority, stressful life events can trigger a downward spiral into major depression
Personality and cognitive vulnerability characteristics, or “diathesis” make some individuals more likely to develop depressive or manic episodes in the face of life events
Childhood stressful life events
victims of physical, sexual and/or emotional abuse are 2-5x more likely to develop depression or bipolar disorder in young adulthood
Depression is more severe more persistent and is more likely to present with a comorbid disorder than those who do not have this history
Reason suggested that early maltreatment is internalized by the child in the form of negative cognitive schemas. Biological theories point to strong effects of child abuse on the brain - associated with death of cells in the hippocampus and amygdala (both involved in mood regulation and emotional memory).
Child abuse associated with dysregulation of the body’s biological stress response system (HPA-axis) and even effects the gene system, impacting how different genese turn on and off through a life span.
Genetics on mood disorders
Bipolar and depression runs in families. First degree relatives with MDD create 2-5x more likely than greater pop.
Bipolar the link is even stronger 7-15x more likely
GWAS
Genetic Wide Association Study - A research design that involves scanning the entire genome to find particular genetic loci that differentiate individuals with a specific disorder and those without.
Neurotransmitters on mood disorders
Dysfunction in three neurotransmitter systems for depression:
1) catecholamine norepinephrine (NE)
2) indoleamine serotonin (5-HT)
3) Dopamine (DA)
All three are also theorized to play a role in the manic episodes of bipolar
Stress and the HPA Axis
HPA Axis - The biological stress response system responsible for the fight or flight response. It is overactive in MDD.
Neuroimaging - Mood Disorders
Both bipolar and unipolar depression have been associated with:
-decreased blood flow and reduced glucose metabolism in the frontal regions of the cerebral cortex, particularly on the left side.
Depression is associated with:
-different limbic structures in processing emotions and emotional memory
-cortical structures involved in higher order decision making, impulse control, judgement and motivation
Gender difference in depression
Women 2x as likely
Women exposed to higher levels of stress in their environment than men, women have heightened sensitivity to stress likely driven by biological and psychological factors
Interpersonal model of suicide
A model that explains suicide ideation and intent as resulting from beliefs that one is a burden on others and feelings of hopelessness and alienation from others.
These can progress to capability of suicide through repeated self harm and suicidal gestures.
