week 3 Mood disorders and Suicide Flashcards
- outline the general characteristics of depression and mania
The experiences of depression and mania are the contributors of all mood disorders.
MAJOR DEPRESSIVE EPISODE;very depressed mood, minimum 2 weeks, cognitive symptoms (such as feeling worthless or being indecisive), altereed sleep patterns, weight gain/loss, loss of interest, to do something is a monumental effort,anhedonia.Untreated usually 4-9 months duration.
Note, if have a manic episode, the diagnosis automatically switches to one of the bipolar disorders.
MANIA;abnormal exaggeration of elation, lasting 1 week. Fast speech, often jump from idea to idea, illusions of grandeur, hyperactivity, requiring little sleep, irritability. Untreated will typically be 3-4 months.Frequently requires hospitalisation for own safety.
HYPOMANIA;manic, but less so than Mania. Might only last 4 days, does not or hardly impairs fn.
- describe the features of the depressive disorders and bipolar disorders
DEPRESSIVE DISORDERS;affects approx 16% In US affects American Indians>Whites>Blacks.Of those with MDD or Dysthymia, 70% are women.
- Major Depressive Disorder; at least 1 major episode of depression, lasts at least 2 weeks, change from previous fn. If have 2 or more episodes but separated by minimum 2 months normalcy,=recurrent. Average lifetime depressive episodes for those with MDD is 4-7. Median duration each episode is 4-5 months.
- Persistent Depressive Disorder (dysthymia);depression lasts at least 2 years(minimum 1 in children) although might have less symptoms than MDD. May remain for 20+ years . Considered more severe due to the chronicity, and has higher comorbidity of other mental illness, and very intractable to treat.
- Double Depression-having both MDD and persistent depression. Even more severe.
- Premenstrual Dysphoric Disorder;-marked incapacitating emotional reactions. different to pmt. considered mood disorder, not endocrine disorder, although associated with signs 1 week prior to menses, and clearing within a few days of starting menses. Symptoms occur prior to most menstrual cycles for previous year.Modd swings, anxiety, tension, bloating, food cravings. significant clinical distress.
- Disruptive Mood Dysregulation Disorder; prolonged and marked irritability. At least 3 major temper outbustrs weekly, irritable b/n outbursts persistently most days, ongoing for at least 1 year. First diagnosed when less than 18 and more than 6 years old, most criteria seen before 10 years of age.
Depressive Disorders, as well as generally being classified as mild/moderate/severe, are also classified via the following specifiers:
a)Psychotic features-hallucinations or delusions
These are mood congruent (seem related to being depressed)or are mood incongruent (seem incongruent with depressed mood-such as delusions of grandeur).
b) Anxious/stress specifier (if have anxiety also, means greater risk of suiciide).
c) Mixed features specifier-predominantly depressive but at least 3 symptoms of mania
d) Melancholic features-all criteria for a major depressive episode met. More severe
e)Catatonic features-stuperous state where muscles are waxy and semi-rigid such that limbs stay where placed, occasional random purposeless movement
f) Atypical features-oversleep,overeat and gain weight
g)peripartum onset
h)seasonal pattern ie depressed in winter (Seasonal Affective Disorder) (SAD thought to be misalignment b/n patient’s circadian rhythym and production of melatonin, and the day-night cycle. Bright light exposure esp 2 hours in morning can help. CBT also helps. patients with SAD have increased melatonin secretion.
BIPOLAR DISORDERS (specifiers used in depressive disorders are also used in bi-polar disorders). Bi-polar disorders tend to have episodes of mania b/n episodes of depression. Rare to develop after age 40. Many suicide during depressive episodes. affects approx 1%
Rapid-cycling specifier is unique however to bi-polar disorders.At least 4 manic or at least 4 depressive episodes in a year. Severe. Poor tx response.Also symptoms usually more severe.Anti-convulsants and mood stabilisers may actually benefit this group more than the traditional antidepressants.20-50% of bi-polars have rapid cycling and more are female. only 3-5% of rapid cyclers continue to have rapid cycling over a 5 year period. (80% return to non rapid cycling patterns after 2 years) (ultra-rapid and ultra ultra rapid mood switch cycles are also possible). General bi polar 50:50 m:f.
1.Bipolar 1 Disorder; has full manic episode/s (2 months normalcy required b/n episodes, otherwise is continuation of same episode).Av age of onset 15-18 years.
2. Bipolar 2 Disorder;av age of onset 19-22 years.Major depressive episodes alternate with hypomania. Often becomes Bipolar 1.
3. Cyclothymic Disorder;milder, more chronic.Usually no normal state in b/n the hypomania and mild depression states cyclically. Still interferes with fn due to chronicity. If was present prior to dx of bipolar, means chance of attaining normalcy (inter-episode recovery) b/n episodes is reduced..Approx 1/3rd will develop Bipolar 1.
60% female. av age onset 12-14 years.
- describe the most characteristic difficulties associated with childhood and adolescent depression and depression in the elderly;
Depressive disorders can occur in childhood (approx 1%, and even as young as 3 months old) but more common in adolescence/young adults. 20-50% of children experience some depressive symptoms insufficient for dx but still somewhat impairing. Depressive episodes in young children more likely boys, but in adolescence is far more females.Adults more females, but elders are 50:50.
Bipolar rates same in children as adults (1%).
Mood disorders whether adult or child, are fairly similar but may manifest differently eg under 3 years of age sad facial expression, irritability, fatigue, fussiness,tantrums. Where there is depression in children, cannot expect that they will “simply grow out of it”. Also the 2 week duration criterion for depression is argued by some as not necessary in children as they are more fluctuant naturally in mood state.
Many children with mania/depression are misdiagnosed with eg ADHD.
CBT very useful.
in the elderly, MDD may easily be missed as signs of itrritability, sleep difficulty, agitation may be attributed to illness or dementia. 50% of Alzheimers have comorbid depression.Anxiety comorbids with 1/3rd of elderly patients with depression, and 1/3rd comorbid with alcohol abuse.
Menopause also increases risk of depression in those previously without it.
The elderly have increased risk of illness and increased risk of loss of social support, and this thus increases risk of depression.Losing a spouse or caring for a sick one, increase depression risk in the elderly.Suicide rates higher in elderly. Optimism is protective against depression.
- discuss biological dimensions to the aetiology of mood disorders
Seems bipolar sufferers do have increased creativity but how this beaks down genetically is not known.
A FAMILY STUDY considers the prevalence of a disorder amongst a sufferer’s first degree relatives.
PROBAND is the one known to have the disorder. A proband’s relatives are 2-3 times more likely to have the disorder than relatives of a non-affected. Increasing severity and earlier onset of the proband for depression, increases chances relatives have.
TWIN STUDIES compare rates of dz in identical twins vs fraternal twins. If genetics play a major part, higher incidence in identicals. Shown that mood disorders are heritable. If 1st twin has mood disorder, 2nd identical twin 2-3 times more likely than a fraternal (or sibling) to have disorder. But if 1st twin has unipolar, risk of 2nd twin having bi-polar v, slim. (ie unipolar and bipolar seem to operate on different gene loci)
63% of variance in depression can be attributable to non-shared environmental factors.
Heritability of depression in women approx 36-44% and in men approx 18-24%. Thus thought environmental effects play larger role for men in depression.
Genetics thought to play larger role in bi-polar than depression.
Now thought 3 separate genetic factors underpin major depression:those associated with cognitive & psychomotor symptoms, those associated with mood, and those associated with melancholic (neurovegetative) symptoms.
Seems non shared environmental factors (from twin studies) contribute far more than shared environmental factors, to interact with biological vulnerability and cause depression.
Bipolar seems it own unique set of genetic factors, but depression and anxiety seem to share genetic vulnerability, and perhaps the environment determines whether will express as anxiety or depression.
LOW SEROTONIN may contribute to depression
Low DOPAMINE may also contribute to depression and seems to occur in stress.
STRESS HYPOTHESIS says overactivity of hypothamic-pituitary axis (HPA) in stress, contributes to depression..
cortisol is elevated in severe depression (and anxiety). Possibly long term elevations of cortisol means less ability for neurogenesis of brain cells. Successful tx of depression seems to increase neurogenesis in the hippocampus (treatment of electroconvulsive therapy and also increasing exercise-behavioural activation).
SLEEP-depressives seem to reach REM sleep sooner and have less time in slow wave sleep (deep sleep).
Sleep pattern disturbances are less pronounced in depressed children than adults.
Very short or very long sleep durations in adults increased the risk of depression.
Bipolars have greater sleep disturbances than normals.
Treating sleep issues can improve tx of depression.
Treating bipolar 1’s with cbt between episodes improves sleep and reduces risk of relapse.
Likely link in SAD patients and sleep pattern/circadian rhythym disturbance.
Abnormal REM profiles or poor sleep quality predicts poorer response to tx.
EEG shows increased activation in right anterior esp prefronal cortex (and less calming alpha waves) in depressives, and seems to remain even after depression episode cleared. Also same pattern observed in offspring of depressed mothers. Bipolars seem to show increased left pre-frontal activation.
- discuss psychological dimensions to the aetiology of mood disorders
Psychological aetiologies are cognitions such as Learned Helplessness or stressors. A trauma or stressor is handled differently by different people, depending on context-eg job loss far more stressful if financially strapped with children than if partner earning well etc etc. Severe stressors precede most depressions except possibly some with melancholic or psychotic features who were cycling through without traumatic/stressful events. Humiliation, loss (death or relationship end) and social rejection are often the stressor which precipitates depression.
Bipolar is also strongly linked to stress as a cause but possibly more positive stressors such as going for a new job, getting married etc more likely to trigger mania. But later cycling seems less related to a specific stress, although stressors make recovery harder.
The DEPRESSIVEcognition IS an attributional style , “It;s my fault “ (internal), ‘ ANOTHER BAD THING WILL HAPPEN” (stable) and extend across various attributions (global).Negative cognitive styles such as this are risk factors for depression.
Both anxiety and depressive sufferers feel helpless and blieve they lack control and ability to change, but in depression, seems even more so to form a feeling of hopelessness.
Other negative cognitive styles include
ARBITRARY INFERENCE ie emphasise negative as opposed to positive aspects of a situation. And
OVERGENERALISATION EG 1 negative remark is thought to overrule all prior positive remarks.
THE DEPRESSIVE COGNITIVE TRIAD is where depressives think negatively about themselves, their world and their future. people may be unaware that their thought patterns are negative.Depression is always associated with some form of negative cognitive style.
Bipolars also have negative cognitions but more focussed on realising ambitions, perfectionism and self-criticism.
Children at risk of depression due to having a depressed mother showed increased negative cognitions under minor stressors.
College roomates living with someone with high cognitive vulnerability for depression, also themselves develpoped more negative cognitive style.
- discuss social and cultural dimensions to the aetiology of mood disorders;
Expressions of depression may vary in cultures eg “I feel blue” in individualistic or “we have lost our meaning” in collectivist.Some call it tiredness of spirit. Differences in prevalence.
Main social/cultural factors contributing to depression onset or maintenance are marital issues, gender and social support issues.
Men have increased risk of developing a mood disorder after a relationship break up. Bipolar and depressive disorders, also contribute to relationship failures.Depression seems to cause men to withdraw from a relationship, whereas relationship issues cause women to experience depression.
Bipolars are less likely to marry, but if do, more likely to divorce. Those who stay married, have higher tx success rates.
Traditional gender roles of women being less independent, may contribute to increased feelings of learnt helplessness or lack of control in women.
Earlier physically maturing girls seem to have more issues with depression.
Social support and connections seem more necessary for females.
women tend to ruminate more re problems (not necessarily helpful), whereas men tend to ignore their feelings or take their mind off by doing activities.
Women who are single, divorced or widowed have higher rates of depression than men.
If live alone, 80% more risk of depression.
Having good social support network helps recover from a depressive episode, but not a manic one.
- describe an integrative theory of mood disorders
considers biological, psychological and social contributions to mood disorders, as well as the relationship between anxiety and depression. Whilst all are important, heritability plays more of a role when young, and environmental when older.
Integrated aopproach says have individual with increased vulnerability, exposed to stressor, and more risk of disorder. One study showed how altering diet for 1 day can restrict Tryptophan intake, and this then tempoorarily lowered serotonin, which induced depressive symptoms in some, and these symptoms more pronounced in those who had cognitive vulnerability. Healthies showed no effect.
- outline biological and drug therapies for treating mood disorders;
One argument says goal of tx is not merely remission, but preventing recurrence.
Good sleep.
Light therapy.
Electroconvulsive therapy.
Drug therapies generally of greater effectiveness for severe depression, and close to placebo effect for mild depression. Generally drugs relieve depressive symptoms in 50% and those taking achieve remission in only 25% of cases. Of those who did not achieve remission after 1st line drug, adding 2nd drug, achieved remisision in 20%. Some patients respond better to one drug than another.
Drug effectiveness and side effects may differ in different ages. Some children on trycyclics have died during exercise with heart issues, but fluoxetine seems safer in children.
Drugs when used, are usually stayed on after resolution for a time, and gradually withdrawn.
Drug options for depression include SSRI’s, Mixed Reuptake Inhibitors, Tricyclic Antidepressants, and Monoamine Oxidase (MOA) Inhibitors.
Fluoxetine (Prozac) (an SSRI) probably most widely used for depression. Thought may increase suicidal thoughts in first few weeks, but after this, reduces them.Side effects of fluoxetine include physical agitation, reduced libido and reduced sexual fn, gi upset, insomnia. But the side effects seem less bothersome than those from Tricyclic antidepressants.
Mixed Reup[take Inhibitors such as Venlafaxine (effexor) blocks re-uptake of norepinephrine and serotonin.
MAO inhibitors block MAO which breaks down neurotransmitters (norepinephrine and serotonin), therefore they pool in the synapse, leading to down-regulation. Possibly best for depression with atypical features. But MAO inhibitors interact with many things, including tyramine which is commonly found in cheese, red wine and beer and this can result in severe hypertension and occasional death. Also adverse reaction with some cold medications.
Tricyclic antidepressants down regulate norepinephrine (and less extent serotonin). High intolerance rate for the side effects of blurred vision, dry mouth, constipation, weight gain, sexual dysfn. Trycyclics are lethal when taken in excessive doses (ie risk of suicide beware).
St John’s wort herb commonly used for depression,of no arguable benefit although pretty safe.
Lithium is often used to treat mania, and is a mood-stabilising drug. 50% of bi-polars respond favourably. Many however decide to discontinue the drug because the like the euphoria of the manic episodes.
Other drugs used for bi-polar are anticonvulsants (eg carbamazepine and valproate) or calcium channel blockers (eg verapamil). Valproate seems better than lithim for rapid cycling symptoms but studies have shown increased risk of suicide cf lithium.
Procedural tx options are;
1 .ELECTROCONVULSIVE THERAPY -under ga and with muscle relaxants, electric shock for <1 sec directly into brain induces seizure.Usually every 2nd day for 6-10 doses. In those who have failed drug tx, severely depressed and psychotic features, is effective in 50% of cases. However need drugs and or psychotherapy after to minimise relapse although still do relapse. Side effects short term memory loss and confusion, which clears after few weeks.
or 2. TRANSCRANIAL MAGNETIC STIMULATION; magnetic coil generates precise and very local electromagnetic pulse. Ga not required. Side effects headache. Comparable effectiveness to anti-depressive drugs. ECT superior for drug resistant severe depression with psychosis.
- outline psychological approaches for treating mood disorders
Positive cognitions.
Marital relationships counselling.
Activation therapy (do something);exercise 3 times weekly as effective as drug therapy for depression.Exercise if maintained, was better than drugs at preventing relapse.
Interpersonal Psychotherapy (IPT)focusses on problem solving in existing relationships and forming new ones.Usually 15-20 sessions.
Cognitive Behavioural Therapy-socratic approach, challenge patient’s negative cognitions.usually 15-20 sessions. CBT can be helpful in prevention in at risk groups also, although the benefit for an adolscent is lessened if living with a parent with depression. Thus recommend treat whole family as a unit.
Cognitive Behavioural Analysis System-combo of CBT and Interpersonal psychotherapy;focusses on problem solving esp for relationships.
Mindfulness cbt.
IPT or CBT obviously a better first choice than drugs for breastfeeding or pregnant.Seems at least equally effective as drugs, often better at preventing relapse.
Combining CBT with a drug seems beneficial for depression. Drugs act faster but cbt more long lasting effects even once stopped. Cbt after benefit is as effective as remaining on drugs for depression.
For BIPOLAR disorder, lithium etc is usually required, but CBT is especially useful also to improve medication compliance, help with sleep cycles, and work on relationship issues. Anti-depressives for bipolars, even in depressive stages, are far less effective, and so cbt is better here.A specific cbt for bipolars is INTERPERSONAL AND SOCIAL RYTHYM THERAPY, which focusses on families communication techniques as family stressor is a big part of relapse.And sleep cycles and coping mechanisms.
- discuss the statistics, causes, risk factors of suicide and the treatment of those at risk of suicide
STATISTICS;Suicide is 11th most common cause of death in the US.far more whites than africans or hispanics (in US). Men more likely successful but women more likely attempt it.Prevalence differs in ethnicities. China far more women complete suicide (but their culture also portrays it as “honourable”). Even some children b/n 2-5 years have attempted.
For every 1000 people in world, every year, 4 will commit suicide, 7 make plans to and 20 consider.
SUICIDAL IDEATION=serious thoughts re, SUICIDAL PLAN=forming specific detailed plan, SUICIDAL ATTEMPT=tried and failed.SSUICIDAL GESTURERS-don’t actually mean to follow through but seek to influence or manipulate or cry for help. College students have suicide as 2nd most leading cause of death.
TYPES; 1. Altruistic eg tradition to avoid dishonour.
2, Egoistic-loss of social support is the provocation for.eg older person who has lost touch with friends.
3. Anomic (anomie=feeling lost/confused) where marked disruption triggers eg loss of a high prestige job.
4. Fatalistic-triggered by feelings of loss of control of one’s destiny.
Some suiciders seem to have thoughts of punishing others by their death.
RISK FACTORS;
1. family history-risk increased if family members have
2.low levels of serotonin (results in impulsivity, irritability and tendency to overeact)
3.existing psychological disorder. More than 80% who suicide have a psychological disorder (usually mood disorder, sometimes substnace use disorder, sometimes impulse control disorder).(but not all. and not all with depression are ever suicidal).
4.alcohol abuse associated with 25-50% of suicides
5.past suicide attempt
6. Stressful life events-one of most important factors.
7. Imitation-sometimes esp amongst teenagers (as many as 5% of their suicides are imitation of someone.
Depression alone could not predict suicide, but depression and impulse control problem and anxiety/agitation does.
Substance abuse and risk takin in teenagers was a predictor of suicide in teenagers.
Borderline personality disorder hallmarked by depression and impulsivity and many of these will attempt suicide although some don’t mean to follow through (but end up going too far…).
TREATMENT-ask questions. Risk of “planting seed” by asking is far less than not discovering the ideation is there and may be acted upon. might even be implicit (person unaware of) but can be discovered with stroop type implicit awareness tests. (has been shown that those testing positively to suicide ideation on implicit test, are at greater risk of later attempting suicide).
Check for recent humiliations which may precipitate.
Check for a plan-if the plan has a specifictime, place and method, the risk of actually attempting suicide is very high. If plan includes finalising affairs also, is even greater risk. Does the person understand full risks? If yes, greater risk. Has the person made efforts not to be discovered in the plan-therefore much greater risk.
ie determine level of suicidal desire, level of suicidal capacity, and suicidal intent.
If suicidal risk high, sing contract of “will not attempt anything without contacting mental health professional”. if will not sign, hospitalise even if against their will.
then treat life stressors, mental illnesses, coping mechansims, etc etc.
Limit access to weapons etc for those at risk.
Telephone hotlines and support services
CBT for problem solving skills etc
