Module 3 - Mood Disorders and Suicide

Question 1

Humoral Theory to mental disorders

Answer 1

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.

Question 2

The first to suggest psychotherapy as a treatment for melancholia

Answer 2

Cicero

Question 3

How do we diagnose mood disorders?

Answer 3

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

Question 4

What are the major theories of the etiology of mood disorders? And some of the key mechanisms that have been suggested in those theories

Answer 4

Cognitve-behavioural
Biological

Question 5

What are key risks for suicide?

Answer 5

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

Question 6

How has the mental health community approached the critical issue of suicide?

Answer 6

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

Question 7

Time frame and key diagnostic features of Bipolar I

Answer 7

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

Question 8

Time frame and key diagnostic features of Bipolar II

Answer 8

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

Question 9

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.

Answer 9

Mood Disorder

Question 10

Imagined Loss

Answer 10

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.

Question 11

DSM-5-TR criteria for Major Depressive Disorder

Answer 11

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)

Question 12

How are mood disorders in the DSM-5-TR classified?

Answer 12

Into two broad categories: unipolar and bipolar

Question 13

Depressive Disorders

Answer 13

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)

Question 14

Bipolar and related disorders

Answer 14

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.

Question 15

Types of Depressive Disorders

Answer 15

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

Question 16

MDD

Answer 16

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

Question 17

Diagnostic criteria for MDD

Answer 17

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.

1. Depressed mood most of the day, nearly everyday (subjective report or observation)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
3. 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.
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable, not merely subjective feelings of being run down or being slowed down).
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (subjective account or observation by others)
9. 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.

Question 18

Persistent Depressive Disorder

Answer 18

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

Question 19

Mania

Answer 19

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

Question 20

Diagnostic Criteria for manic episode

Answer 20

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:

1. Inflated self-esteem/grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractability
6. Increase in goal-directed activity
7. 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

Question 21

hypomania

Answer 21

less severe form of mania that involves a similar number of symptoms, but those symptoms only need to be present for 4 days

Question 22

Cyclothymia

Answer 22

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.

Question 23

Rapid Cycling Specifier

Answer 23

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

Question 24

Seasonal Affective Disorder (SAD)

Answer 24

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)

Question 25

Mood disorder with Peri (last month of gestation) or Postpartum onset

Answer 25

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

Question 26

Premenstrual Dysphoric Disorder (PMDD)

Answer 26

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

Question 27

Psychological and Environmental Causal Factors of mood disorders

Answer 27

Psychological -
-Personality theories
-Cognitive theories
-Interpersonal models

Environmental -
-Life stress perspective
-Childhood stressful life events

Question 28

Biological causal factors of mood disorders

Answer 28

Genetics
Neurotransmitters
Stress and the Hypothalamic-pituitary-adrenal axis

Question 29

Etiology of mood disorders

Answer 29

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.

Question 30

Personality theories of mood disorders

Answer 30

Personality models:
1) 5 factor model
2) Behavioural inhibition system/behavioural activation system (BIS/BAS)

Question 31

5 factor model of personality

Answer 31

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

Question 32

Behavioural inhibition system/behavioural activation system (BIS/BAS)

Answer 32

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

Question 33

Cognitive theories of mood disorders

Answer 33

Diathesis stress model

Question 34

Cognitive distortions

Answer 34

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

Question 35

Interpersonal models

Answer 35

stress generation hypothesis
interpersonal model of depression

Behaviours:
Excessive reassurance seeking
Negative feedback seeking

Question 36

Stress generation hypothesis

Answer 36

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

Question 37

Life Stress perspective

Answer 37

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

Question 38

Childhood stressful life events

Answer 38

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.

Question 39

Genetics on mood disorders

Answer 39

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

Question 40

GWAS

Answer 40

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.

Question 41

Neurotransmitters on mood disorders

Answer 41

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

Question 42

Stress and the HPA Axis

Answer 42

HPA Axis - The biological stress response system responsible for the fight or flight response. It is overactive in MDD.

Question 43

Neuroimaging - Mood Disorders

Answer 43

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

Question 44

Gender difference in depression

Answer 44

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

Question 45

Interpersonal model of suicide

Answer 45

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.