Depression%20%26%20Suicide%20Chapter%206

Depression%20%26%20Suicide%20Chapter%206 - Mood and Suicide...

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Unformatted text preview: Mood and Suicide Mood Overview Overview Defining Feature: Gross deviations in mood Types of DSM-IV-TR Depressive Disorders – Major depressive disorder – Dysthymic disorder – Double depression Types of DSM-IV-TR Bipolar Disorders – Bipolar I disorder – Bipolar II disorder – Cyclothymic disorder Major Depression Major Overview and Defining Features – – – Extremely depressed mood – Lasting at least 2 weeks Extremely Cognitive symptoms (e.g., worthlessness or indecision) Physical symptoms (+/- weight; +/- sleep; +/- activity Physical level; fatigue) level; – Anhedonia Anhedonia – Thoughts of death Somatic complaints and anhedonia may be better indicators Major Depressive Disorder – Single episode – Highly unusual Single Average duration (untreated) = 9 months Average – Recurrent episodes (separated by two months)– More Recurrent common common Dysthymia Dysthymia Overview and Defining Features – Milder symptoms than major depression – Persists at least 2 years – Can persist over long periods – > 20 years Onset & Prognosis – Late onset – Typically in the early 20s – Early onset – Before age 21 Greater chronicity, poorer prognosis, evidence of Greater higher familial rates of dysthymia higher Double Depression Overview and Defining Features Overview – Major depressive episodes and dysthymic Major disorder disorder – Dysthymic disorder often develops first Prognosis – Associated with severe psychopathology – Associated with a problematic future course – High recurrence when dysthymia is untreated Bipolar I Disorder Bipolar Overview and Defining Features – Essential feature – occurrence of one or more manic episodes Essential or mixed episodes (depression and mania) or – Individuals will typically experience a major depressive episode. – Distinct period of elevated or irritable mood (1 week) Inflated self-esteem or grandiosity Decreased need for sleep More talkative; pressured sleep Flight of ideas; racing thoughts Distractibility Increase in goal-directed behavior Excessive involvement in pleasurable activities Mania Course – – – – Average age on onset is 18 years Can begin in childhood Tends to be chronic Suicide is a common consequence Bipolar II Disorder Bipolar Overview and Defining Features – Alternating major depressive and hypomanic Alternating episodes episodes Course – Average age of onset is 22 years – Can begin in childhood – 10 to 13% of cases progress to full Bipolar I 10 disorder disorder – Tends to be chronic Overview and Defining Features – – – Cyclothymic Disorder Cyclothymic More chronic version of bipolar disorder Manic and MD episodes are less severe Manic or depressive mood states persist for long Manic periods – Must last for at least 2 years for adults – Must last at least 1 year for children/adolescents Course – – – – Average age of onset is about 12 or 14 years Tends to be chronic and lifelong Most are female High risk for developing Bipolar I or II disorder Bipolar I Bipolar II Cyclothymia Mania Hypomania Depression Symptom Specifiers Symptom Specifiers Symptom – Atypical – Oversleep, overeat, weight gain, anxiety – Melancholic – Severe depressive and somatic symptoms Melancholic (sleep disruption, appetite loss, decreased libido, anhedonia) (sleep – Chronic – Major depression only, lasting 2 years – Catatonic – Absence of movement, very serious – Psychotic – Mood congruent hallucinations/delusions – Postpartum – Manic or depressive episodes after childbirth Course Specifiers Course Specifiers Course – Longitudinal course History of mood disturbance History of recovery from depression and/or mania – With and Without Full Interepisode recovery – Rapid cycling pattern For Bipolar I and II Four manic or depressive episodes in a year – Seasonal pattern Seasonal Depressive symptoms likely during certain season Depressive Epidemiology Lifetime Prevalence Lifetime – 16.1% for Major Depression – 3.6% for Dysthymia – 1.3% for Bipolar Sex Differences – Females > Males for MDD Females – Difference disappears at age 65 Difference – Females = Males for Bipolar Disorders Females Fundamentally Similar in Children and Adults Fundamentally Prevalence of Depression Same Across Subcultures Relation Between Anxiety and Depression – Most depressed persons are anxious – Not all anxious persons are depressed Tripartite Model Tripartite Negative Affect Worry Poor concentration Irritability Crying Guilt Fatigue Worthlessness Hopelessness Pure Anxiety (somatic tension) Apprehension Tension Edginess Trembling Pure Depression (low positive affect) Depressed mood Loss of interest Lack of pleasure Loss of sex drive Familial and Genetic Influences Family Studies – Rate is 2 to 3 times higher in family members Twin Studies Twin – – – – Concordance rates high for MZ twins Severe cases have a stronger genetic contribution Heritability higher for females Heritability Vulnerability for unipolar or bipolar disorder Appear to be inherited separately Genetic contribution appears to be higher for Bipolar Neurobiological Influences Neurobiological Neurotransmitters – Linked to low levels of serotonin – Serotonin regulates other neurotransmitters Serotonin “Permissive” hypothesis Balance is more important than absolute levels. Endocrine System – Elevated cortisol “stress hormone” increases energy; attention; lowered pain sensitivity – May reduce ability to develop new neurons May Sleep Disturbance Sleep – Hallmark of most mood disorders – REM sleep more quickly, less slow wave, “deep” sleep Stress Stress Stress is strongly related to mood disorders – – – Poorer response to treatment Longer time before remission Better predictor of initial episodes Better Relation between context of events and mood Relation Reciprocal-gene environment model – Not just a stress depression relation Not – Genetically predisposed to entering/creating stressful Genetically situations increased chance of depression situations Stress alone not enough – interaction with psychological characteristics Learned Helplessness Learned Learned Helplessness Theory of Depression – Animal research – Lack of perceived control over life events Depressive Attributional Style – Internal attributions – Stable attributions – Global attribution – All three contribute to a sense of hopelessness but All it is the hopelessness that leads to depression. it Beck’s Cognitive Theory Beck’s Depression is result of distorted thought – Depressed persons engage in cognitive errors – A tendency to interpret life events negatively Cognitive Errors – – – – Arbitrary inference Overgeneralization Dichotomous thinking Dichotomous Personalization The Depressive Cognitive Triad – Negative thoughts about self, world, and future – May result in and from depression Social and Cultural Factors Social Marriage and Interpersonal Relationships – Marital dissatisfaction and depression are strongly linked, Marital especially in males – Martial dissatifaction depression – Depression marital conflict – – – – 2:1 Females over males 2:1 Except bipolar disorders Found across the world May be due to socialization Gender Imbalance Gender Social Support – Related to depression – Lack of support predicts depression – Substantial support predicts recovery from depression Biological Treatment Biological Tricyclics – Widely used (e.g., Tofranil, Elavil) – Block reuptake of NE and other neurotransmitters – Problems: long uptake (2 to 8 weeks), Negative Side Effects Problems: Common, May be Lethal in Excessive Doses Common, – – – – Rarely used Inhibitors block MAO which breaks down 5HT & NE As or slightly more effective than tricyclics Problems: avoid foods containing Tyramine (e.g., beer, red wine, Problems: cheese), can interact dangerously cheese), Most widely used (e.g., Prozac, Celexa, Lexapro, Paxil, Zoloft) Specifically Block Reuptake of Serotonin Pose No Unique Risk of Suicide or Violence Side effects are common (upset stomach, insomnia, physical Side agitation, sexual dysfunction) but MORE tolerable agitation, Monoamine Oxidase Inhibitors Selective Serotonin Re-uptake Inhibitors – – – – Biological Treatment Biological Lithium – – – Common salt (mineral found in natural environment) Primary drug of choice for bipolar disorders Anti-convulsants also commonly used (Tegretol and/or Anti-convulsants Depakote). Less effective at reducing suicide Depakote). – Problems: Side effects may be severe and must be Problems: carefully monitored via blood tests carefully Electroconvulsive Therapy Electroconvulsive – Brief electrical current to the brain (bilateral or Brief unilateral) to create temporary seizures – Usually 6 to 10 treatments are required Usually – effective for cases of severe depression – Problems: short-term memory loss (possible longterm); short-term confusion; relapse is common Psychological Treatment Psychological Cognitive Therapy – – – Addresses cognitive errors in thinking Addresses Also includes behavioral components Collaborative approach, Structured & time-limited Behavioral Activation – Involves increased contact with reinforcing events Interpersonal Psychotherapy – Focus on problematic interpersonal relationships Focus Outcomes for CBT and IPT Outcomes – Comparable to medications – Combined treatment more useful for chronic depression – Maintenance treatment important to prevent relapse Psychological Treatment Psychological Psychological Treatment for Bipolar Disorder – Can help with medication compliance – Help get patients to keep regular schedules, Help which may reduce the likelihood of starting a new mood episode mood – Miklowitz emphasizes the role of family tension in Miklowitz relapses. relapses. Didactics about illness Work on family communication Suicide Suicide Eighth leading cause of death in US – Age 25-34 – Actual numbers may be higher White and Native American phenomenon Suicide rates increasing, particularly in young Gender Differences – – Males are more likely to commit suicide (4-5x higher) Females are more likely to attempt suicide (3x higher) Indices of Suicidal Behavior – Suicidal attempts (50:1 to 200:1) – Suicidal ideations Suicide Risk Factors Suicide Suicide in the family (risk 6x higher) Low serotonin levels – Related to depression, impulsivity, and Related aggression aggression Preexisting psychological disorder – Most often depression, not always Alcohol use/abuse (in 25 – 50% suicides) Past suicidal behavior Shameful/humiliating stressor Publicity/media coverage: suicide clusters Suicide Treatment/intervention Suicide Never be afraid of asking about suicide Well-developed plan? Means? No suicide contract Hospitalization Risk factors ...
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