Mood Disorders: Mood Disorders: Depression, Mania, & Bipolar Depression, Mania, & Bipolar

DisorderDisorder

What is Mood? What is Mood?

““Mood is a Mood is a a conscious state of mind a conscious state of mind or predominant emotion” or predominant emotion”

Webster’s DictionaryWebster’s Dictionary

What is a Mood Disorder? What is a Mood Disorder?

Involves disabling disturbances in Involves disabling disturbances in emotions that are markedly different emotions that are markedly different from normal functioningfrom normal functioning

Can also include cognitive & Can also include cognitive & behavioral disturbances behavioral disturbances

Generally occurs in discrete episodesGenerally occurs in discrete episodes– Depression – extreme sadness Depression – extreme sadness – Mania – extreme elation and irritability Mania – extreme elation and irritability

Types of Mood Types of Mood DisordersDisorders

Main Distinction: unipolar or bipolarMain Distinction: unipolar or bipolar– Unipolar: only one end of the emotion spectrumUnipolar: only one end of the emotion spectrum

Major Depressive EpisodeMajor Depressive Episode Manic EpisodeManic Episode

– Bipolar: cycling between both ends of the emotion Bipolar: cycling between both ends of the emotion spectrum spectrum

Bipolar Disorder Bipolar Disorder

Other DisordersOther Disorders– Dysthymia: mild, chronic form of depression Dysthymia: mild, chronic form of depression – Cyclothymia: similar to bipolar, but a more mild Cyclothymia: similar to bipolar, but a more mild

form of mania (hypomania)form of mania (hypomania)

Bipolar DisordersBipolar Disorders

Bipolar I DisorderBipolar I Disorder Bipolar II DisorderBipolar II Disorder Cyclothymic DisorderCyclothymic Disorder

Manic Episode: DSM Manic Episode: DSM CriteriaCriteria

A distinct period of abnormally and persistently elevated, A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).duration if hospitalization is necessary).

During the period of mood disturbance, three (or more) of the following During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:been present to a significant degree:(1)(1) inflated self-esteem or grandiosityinflated self-esteem or grandiosity(2)(2) decreased need for sleep (e.g., feels rested after only 3 hours decreased need for sleep (e.g., feels rested after only 3 hours of sleep)of sleep)(3)(3) more talkative than usual or pressure to keep talking more talkative than usual or pressure to keep talking (4)(4) flight of ideas or subjective experience that thoughts are racingflight of ideas or subjective experience that thoughts are racing(5)(5) distractibility (i.e., attention too easily drawn to unimportant distractibility (i.e., attention too easily drawn to unimportant stimuli)stimuli)(6)(6) increase in goal-directed activity or psychomotor agitationincrease in goal-directed activity or psychomotor agitation(7)(7) excessive involvement in pleasurable activities that have a excessive involvement in pleasurable activities that have a high high potential for painful consequencespotential for painful consequences

Manic Episode Rule-Manic Episode Rule-OutsOuts

do not meet criteria for a Mixed Episode do not meet criteria for a Mixed Episode – Mixed episode = both manic and depressed nearly everyday for Mixed episode = both manic and depressed nearly everyday for

at least one weekat least one week

marked impairment in occupational functioning or in usual marked impairment in occupational functioning or in usual social activities or relationships with others, or to social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, necessitate hospitalization to prevent harm to self or others, or there are psychotic featuresor there are psychotic features

not due to the direct physiological effects of a substance not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)general medical condition (e.g., hyperthyroidism)

Note: Manic-like episodes that are clearly caused by Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disordertoward a diagnosis of Bipolar I Disorder

Bipolar I Bipolar I

1 or more manic episodes; may have 1 or more manic episodes; may have had past depressive episodes or nothad past depressive episodes or not

Lifetime PrevalenceLifetime Prevalence: about 1%; equal in : about 1%; equal in men and womenmen and women

Course and PrognosisCourse and Prognosis: poorer prognosis : poorer prognosis than MDDthan MDD– 45% have one more episode 45% have one more episode – only 50-60% achieve control over Sx with lithiumonly 50-60% achieve control over Sx with lithium– 40% develop a chronic disorder40% develop a chronic disorder

Bipolar IIBipolar II

recurrent major depressive episodes recurrent major depressive episodes with hypomanic episodeswith hypomanic episodes– Hypomania - All the criteria of a Manic Hypomania - All the criteria of a Manic

episode except criterion C (marked episode except criterion C (marked impairment)impairment)

– NOT full-blown manic episodes, if an NOT full-blown manic episodes, if an individual does experience a manic individual does experience a manic episode, they are then diagnosed with episode, they are then diagnosed with Bipolar I DisorderBipolar I Disorder

matter of differential diagnosismatter of differential diagnosis

Bipolar DisorderBipolar Disorder

Bipolar IBipolar I Alternation of full Alternation of full

manic and manic and depressive depressive episodesepisodes

Average onset is 18 Average onset is 18 yearsyears

Tends to be chronicTends to be chronic High risk for suicideHigh risk for suicide

Bipolar IIBipolar II Alternation of Major Alternation of Major

Depression with Depression with hypomaniahypomania

Average onset is 22 Average onset is 22 yearsyears

Tends to be chronicTends to be chronic 10% progess to full 10% progess to full

biploar I disorderbiploar I disorder

CyclothymiaCyclothymia

A.A. For at least two years (one year for children and For at least two years (one year for children and adolescents) presence of numerous hypomanic adolescents) presence of numerous hypomanic episodes and numerous periods with depressed episodes and numerous periods with depressed mood or loss of interest or pleasure that did not mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depressionmeet criterion A (5 symptoms) of Major Depression

B.B. During a two-year period (1 year in children and During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at depressive symptoms for more than tow months at a timea time

C.C. No evidence of MDD or Manic episode during the No evidence of MDD or Manic episode during the first two years of disturbancefirst two years of disturbance

D.D. No psychotic disorderNo psychotic disorderE.E. No organic causeNo organic cause

Mania EtiologyMania Etiology

better-suited for the biological model better-suited for the biological model – not normally distributed in the population not normally distributed in the population – Symptoms are very marked and severeSymptoms are very marked and severe

not necessarily precipitated by a positive life not necessarily precipitated by a positive life event & can override negative eventsevent & can override negative events– further evidence in favor of diathesisfurther evidence in favor of diathesis

Familial Pattern seenFamilial Pattern seen

Twin and adoption studiesTwin and adoption studies

What Does Mania Look What Does Mania Look Like?Like?

Client 1: Mary

Depressive DisordersDepressive Disorders

Major Depressive Disorder (single, Major Depressive Disorder (single, recurrent)recurrent)

[Major Depressive Disorder: [Major Depressive Disorder: Postpartum onset]**Postpartum onset]**

Dysthymic DisorderDysthymic Disorder Double DepressionDouble Depression Postpartum depression as a Postpartum depression as a

specifierspecifier

What Does Depression Look What Does Depression Look Like? Like?

– SadnessSadness– Suicidal ThoughtsSuicidal Thoughts– TirednessTiredness– BoredomBoredom– Unwilling to get out Unwilling to get out – Insomnia Insomnia

Depressive Depressive Episode/Disorder:Episode/Disorder:

DSM CriteriaDSM Criteria Five or more of the following during the same 2-week Five or more of the following during the same 2-week

period that represent a change from usual period that represent a change from usual functioning including either (1) depressed mood or functioning including either (1) depressed mood or (2) loss of interest. (2) loss of interest.

Sad, depressed mood, most of the day, nearly every Sad, depressed mood, most of the day, nearly every day for two weeksday for two weeks

Loss of interest and pleasure in usual activitiesLoss of interest and pleasure in usual activities Difficulties sleepingDifficulties sleeping Shift in activity level Shift in activity level Changes in appetite and weight loss/gainChanges in appetite and weight loss/gain Loss of energy, fatigueLoss of energy, fatigue Negative self-concept, self-blame, guilt, Negative self-concept, self-blame, guilt,

worthlessnessworthlessness Difficulty concentrating Difficulty concentrating Recurrent thoughts of death or suicide Recurrent thoughts of death or suicide

Depression Diagnosis Depression Diagnosis Rule-OutsRule-Outs

The symptoms do not meet criteria for a Mixed Episode The symptoms do not meet criteria for a Mixed Episode

The symptoms cause clinically significant distress or The symptoms cause clinically significant distress or impairment in social, occupational, or other important impairment in social, occupational, or other important areas of functioning.areas of functioning.

The symptoms are not due to the direct physiological The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., medication) or a general medical condition (e.g., hypothyroidism).hypothyroidism).

The symptoms are not better accounted for by The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.psychotic symptoms, or psychomotor retardation.

Major DepressionMajor Depression

MDD, Single MDD, Single episodeepisode

Absence of Absence of mania or mania or hypomaniahypomania

MDD, RecurrentMDD, Recurrent 2 major 2 major

depression depression episodes, episodes, separated by at separated by at least a 2 month least a 2 month period with more period with more or less normal or less normal functioning/moodfunctioning/mood

Dysthymic Disorder: Dysthymic Disorder: SymptomsSymptomsA.A. Depressed/irritable moodDepressed/irritable moodB.B. Presence of two of the following:Presence of two of the following: Appetite disturbanceAppetite disturbance Sleep disturbanceSleep disturbance Low energy/fatigueLow energy/fatigue Poor concentration of difficulties making decisionPoor concentration of difficulties making decision Feelings of hopelessnessFeelings of hopelessnessC. Present for two year period (one year in children and C. Present for two year period (one year in children and

adolescents)adolescents)D. No evidence of a Major Depressive Epidsode during D. No evidence of a Major Depressive Epidsode during

the first two years (one year for children)the first two years (one year for children)E. No manic or hypomanic episodeE. No manic or hypomanic episodeF. No chronic psychotic disorderF. No chronic psychotic disorderG. Not related to organic factorsG. Not related to organic factors

““Double Depression”Double Depression”

Not a diagnosisNot a diagnosis Meet diagnostic criteria for both Meet diagnostic criteria for both

MDD and Dysthymic DisorderMDD and Dysthymic Disorder

PrevalencePrevalence

Point prevalencePoint prevalence is the percentage is the percentage of the population who have the of the population who have the disorder at a particular time or disorder at a particular time or over a given period of time.over a given period of time.

Lifetime prevalenceLifetime prevalence is the is the percentage of individuals who have percentage of individuals who have ever had a specific disorder at any ever had a specific disorder at any time.time.

Facts About Facts About Depression Depression

Major depression is the single most Major depression is the single most common psychiatric disorder in the U.S. common psychiatric disorder in the U.S.

The point prevalence rate over a 1-year The point prevalence rate over a 1-year period is 8% for men and 13% for period is 8% for men and 13% for women. women.

Lifetime prevalence rate is 12.7% for Lifetime prevalence rate is 12.7% for men and 21.3% for women. men and 21.3% for women.

In addition, depression is the most In addition, depression is the most common factor leading to suicide.common factor leading to suicide.

What Does Depression What Does Depression Look Like?Look Like?

Client 1: Mary Client 2: Barbara Client 3: Evelyn

Video Reactions? Video Reactions?

What symptoms of depression did What symptoms of depression did you notice in these clients? you notice in these clients?

Any evidence of suicidal thoughts? Any evidence of suicidal thoughts?

Which patient might be more likely Which patient might be more likely to commit suicide? Why? to commit suicide? Why?

Etiology: BiologicalEtiology: Biological

Genetic FactorsGenetic Factors– Family, twin, and adoption studies suggest Family, twin, and adoption studies suggest

that depression in hereditary that depression in hereditary – More severe the depression in an More severe the depression in an

individual, more likely that relative have individual, more likely that relative have depression as well depression as well

– MDD concordance: 40% MZ, 10% DZMDD concordance: 40% MZ, 10% DZ– Mania concordance: 75% MZ, 25% DZMania concordance: 75% MZ, 25% DZ– Severity of disorder is due to strength of Severity of disorder is due to strength of

genetic loading genetic loading

Etiology: Biological Etiology: Biological cont.cont. Adoption studies Adoption studies

– More mood disorders occur in the More mood disorders occur in the biological relatives of those with biological relatives of those with mood disordersmood disorders

– both unipolar and bipolar disordersboth unipolar and bipolar disorders– severity linked to the strength of the severity linked to the strength of the

genetic loading genetic loading

Etiology: Biological Con’tEtiology: Biological Con’t

Neurochemical FactorsNeurochemical Factors– NeurotransmittersNeurotransmitters

NorepinephrineNorepinephrine SerotoninSerotonin DopamineDopamine

– Not clear what processes are dysfunctional Not clear what processes are dysfunctional (production, reuptake, chemical breakdown, (production, reuptake, chemical breakdown, etc.)etc.)

– Neuroendocrine changesNeuroendocrine changes Hypothyroidisim Hypothyroidisim

Research on Research on NeurotransmittersNeurotransmitters

norepinephrine & serotoninnorepinephrine & serotonin– Implicated in mania and depressionImplicated in mania and depression

effectiveness of antidepressants effectiveness of antidepressants – most drugs in psychiatry discovered by most drugs in psychiatry discovered by

accidentaccident Not as simple a relationship as Not as simple a relationship as

previously thoughtpreviously thought– E.g. TCA and MAOI drugsE.g. TCA and MAOI drugs

Permissive hypothesisPermissive hypothesis

Beck’s Cognitive Theory Beck’s Cognitive Theory of Depressionof Depression

distortions of reality & depressogenic distortions of reality & depressogenic cognitions result in depression cognitions result in depression

schema filters and organizes schema filters and organizes experiences to store beliefs and experiences to store beliefs and knowledge about ourselvesknowledge about ourselves

cognitive triad of negative schemascognitive triad of negative schemas– negative view of the self, the world, and negative view of the self, the world, and

the futurethe future

Cognitive Theory Con’tCognitive Theory Con’t

negative automatic thoughts negative automatic thoughts – further bias that individuals’ view of further bias that individuals’ view of

himself, the world, and the future himself, the world, and the future – e.g., arbitrary inference, selective e.g., arbitrary inference, selective

abstraction, overgeneralization, abstraction, overgeneralization, magnification, etc. magnification, etc.

thoughts focused on experiences of loss and thoughts focused on experiences of loss and failure failure

research supports the presence of distorted, research supports the presence of distorted, automatic cognitions automatic cognitions – the causal relationship of these factors not the causal relationship of these factors not

establishedestablished

Helplessness/Helplessness/Hopelessness ModelHopelessness Model

Seligman’s learned helplessness Seligman’s learned helplessness model started as a conditioning model started as a conditioning model with dogs model with dogs

those who were exposed to those who were exposed to uncontrollable aversive situations uncontrollable aversive situations would develop depression that would develop depression that was rooted in feelings of was rooted in feelings of helplessnesshelplessness

Attributional ModelAttributional Model

Abramson - Attribution of lack of control over Abramson - Attribution of lack of control over stress leads to anxiety and depressionstress leads to anxiety and depression

Cognitive distortions affect the interpretation Cognitive distortions affect the interpretation of causes of events in people’s lives. of causes of events in people’s lives.

biased attributional style (i.e., a cognitive biased attributional style (i.e., a cognitive style regarding beliefs about the causes of style regarding beliefs about the causes of events) characterized by internal, stable, and events) characterized by internal, stable, and global attributions.global attributions.

Seligman and BeckSeligman and Beck

SeligmanSeligmanAttributions are:Attributions are: InternalInternal StableStable GlobalGlobal

I am inadequate (internal) at I am inadequate (internal) at everything (global) and I everything (global) and I always will be (stable).always will be (stable).

““Dark glasses about why Dark glasses about why things are bad”things are bad”

Interpretation (theory)Interpretation (theory)

BeckBeckNegative interpretations about:Negative interpretations about: ThemselvesThemselves Immediate world (their Immediate world (their

place)place) Future (their place)Future (their place)

I am not good at school (self). I I am not good at school (self). I hate this campus (world). hate this campus (world). Things are not going to go Things are not going to go well in college (future).well in college (future).

““Dark glasses about what is Dark glasses about what is going on”going on”

DescriptionDescription

Attributional Model Con’tAttributional Model Con’t

Internal - attribute negative events to Internal - attribute negative events to own failingsown failings

Stable - belief that causes of negative Stable - belief that causes of negative events remain constant events remain constant

Global - assume causes of negative Global - assume causes of negative events have broad and general effectsevents have broad and general effects

research supports the hopelessness research supports the hopelessness model model – but cannot establish causal relationshipbut cannot establish causal relationship

Major Depression: Social Major Depression: Social and Cultural Factorsand Cultural Factors

Stressful life eventsStressful life events Social support (marital Social support (marital

relationship) (see chart)relationship) (see chart) GenderGender Culture (see chart)Culture (see chart)

Marital Status and MDDMarital Status and MDDPercentage w/MDDPercentage w/MDD

2.1 2.1

2.8

6.3

0

1

2

3

4

5

6

7

Married Widowed Never M. M/D/W

Married

Widowed

Never M.

M/D/W

Ethnicity and Prevalence Ethnicity and Prevalence of MDDof MDDPercentage by EthnicityPercentage by Ethnicity

3.1

4.4

5.1 4.9

0

1

2

3

4

5

6

Af. Am Latina White Average

Af. Am

Latina

White

Average

Gender Differences in Gender Differences in Depression Depression

Dr. Susan Nolen-HoeksemaDr. Susan Nolen-Hoeksema Women diagnosed twice as often as Women diagnosed twice as often as

men men difference not evident in childhooddifference not evident in childhood

– boys and girls are just as likely to boys and girls are just as likely to experience depressionexperience depression

– Changes in preteen yearsChanges in preteen years What factors may be involved in the What factors may be involved in the

development of these differences? development of these differences?

Diathesis-Stress ModelDiathesis-Stress Model

Neither biological nor environmental Neither biological nor environmental and personal factors alone can and personal factors alone can produce depression produce depression

a biological vulnerability (or diathesis) a biological vulnerability (or diathesis) interacts with life stressors to produce interacts with life stressors to produce depression depression – For example, a neurotransmitter For example, a neurotransmitter

dysfunction may interact with life stressors dysfunction may interact with life stressors (e.g., death of a loved one) to produce (e.g., death of a loved one) to produce depressiondepression

Diathesis-Stress ExampleDiathesis-Stress Example

No Life Event Life Event

Depre

ssio

n

Low NE

Normal NE

Comorbidity with AnxietyComorbidity with Anxiety

distinguishing depression from anxiety difficultdistinguishing depression from anxiety difficult

Watson & Clark: tripartite model Watson & Clark: tripartite model

– Negative affectivity (NA) - pervasive individual Negative affectivity (NA) - pervasive individual differences in negative emotionality and self-conceptdifferences in negative emotionality and self-concept

Common to anxiety & depressionCommon to anxiety & depression

– Anhedonia - lack of experiencing pleasure Anhedonia - lack of experiencing pleasure specific to depressionspecific to depression

– Anxious arousal - physiological symptoms of anxiety Anxious arousal - physiological symptoms of anxiety specific to anxiety disorders specific to anxiety disorders

Psychological Psychological Treatments for Treatments for

Depression Depression Psychodynamic TherapiesPsychodynamic Therapies

Cognitive-Behavioral TherapiesCognitive-Behavioral Therapies– Beck Cognitive TherapyBeck Cognitive Therapy– Social Skills TrainingSocial Skills Training– Behavioral ActivationBehavioral Activation

Interpersonal TherapyInterpersonal Therapy

Cognitive Therapy

Procedures

16 weeks of treatment

Extensive Assessment:

Placebo & Clinical Management

Depression Collaborative Research ProgramInterpersonal

Psychotherapy

T

Treatment Groups

Outcome MeasuresDepressive SymptomsOverall symptomotology and life functioningFunctioning in treatment specific domains

Results:

Post-Treatment

•Equivalent success in three active treatments over placebo

•Medication was faster

•IPT better than CBT for more severely depressed patients

•Particular treatments effected change in expected domains

Results

Follow-up-18 months

•Equivalent success in three active treatments

•Only 20 to 30% of recovered patients were still well

•Patients in IPT report more satisfaction with treatment

•IPT and CBT patients more likely to report that treatment affected capacity to establish and maintain relationships and to understand source of their depression

MedicationImiprimine

Many Controversial Issues

Biological Therapies for Biological Therapies for Depression Depression

Drug TherapiesDrug Therapies– TricyclicsTricyclics– Selective serotonin reuptake Selective serotonin reuptake

inhibitorsinhibitors– Monoamine oxidase inhibitorsMonoamine oxidase inhibitors

Electroconvulsive Therapy Electroconvulsive Therapy

Mood Disorders: Mood Disorders: PrevalencePrevalence

DisordersDisorders

Major DepressionMajor Depression

DysthymiaDysthymia

Bipolar IBipolar I

Bipolar IIBipolar II

MDD (Postpartum)MDD (Postpartum)

PrevalencePrevalence

4.9%4.9%

3.2%3.2%

0.8%0.8%

0.50.5

13% 13%

SuicideSuicide

88thth leading cause of death in the U.S. leading cause of death in the U.S. Overwhelmingly white phenomenaOverwhelmingly white phenomena Suicide rates also quite high in Native Suicide rates also quite high in Native

AmericanAmerican Rate of suicide is increasing in Rate of suicide is increasing in

adolescents and elderlyadolescents and elderly Males are more likely to commit suicideMales are more likely to commit suicide Females are more likely to attempt Females are more likely to attempt

suicide (except China)suicide (except China)

5 Myths and Facts 5 Myths and Facts About SuicideAbout Suicide

Myth #1Myth #1:: People who talk People who talk

about killing about killing themselves themselves rarely commit rarely commit suicide.suicide.

Fact:Fact: Most people who Most people who

commit suicide commit suicide have given some have given some verbal clues or verbal clues or warnings of their warnings of their intentionsintentions

5 Myths and Facts 5 Myths and Facts About SuicideAbout Suicide

Myth #2:Myth #2: The suicidal The suicidal

person wants to person wants to die and feels die and feels there is no there is no turning back.turning back.

Fact:Fact: Suicidal people Suicidal people

are usually are usually ambivalent about ambivalent about dying; they may dying; they may desperately want desperately want to live but can not to live but can not see alternatives see alternatives to problems.to problems.

5 Myths and Facts 5 Myths and Facts About SuicideAbout Suicide

Myth # 3:Myth # 3: If you ask If you ask

someone about someone about their suicidal their suicidal intentions, you intentions, you will only will only encourage them encourage them to kill to kill themselves.themselves.

Fact:Fact: The opposite is The opposite is

true. Asking true. Asking lowers their lowers their anxiety and helps anxiety and helps deter suicidal deter suicidal behavior. behavior. Discussion of Discussion of suicidal feelings suicidal feelings allow for accurate allow for accurate risk assessment.risk assessment.

5 Myths and Facts 5 Myths and Facts About SuicideAbout Suicide

Myth # 4:Myth # 4: All suicidal All suicidal

people are people are deeply deeply depressed.depressed.

Fact:Fact: Although depression Although depression

is usually associated is usually associated with depression, not with depression, not all suicidal people all suicidal people are obviously are obviously depressed. Once depressed. Once they make the they make the decision, they may decision, they may appear appear happier/carefree.happier/carefree.

5 Myths and Facts 5 Myths and Facts About SuicideAbout Suicide

Myths # 5:Myths # 5: Suicidal people Suicidal people

rarely seek rarely seek medical medical attention.attention.

Fact:Fact: 75% of suicidal 75% of suicidal

individuals will individuals will visit a physician visit a physician within the month within the month before they kill before they kill themselves. themselves.

Sociodemographic Risk Sociodemographic Risk FactorsFactors MaleMale > 60 years> 60 years Widowed or DivorcedWidowed or Divorced White or Native AmericanWhite or Native American Living alone (social isolation)Living alone (social isolation) Unemployed (financial difficulties)Unemployed (financial difficulties) Recent adverse life eventsRecent adverse life events Chronic IllnessChronic Illness

Clinical Risk FactorsClinical Risk Factors

Previous AttemptsPrevious Attempts Clinical depression or schizophreniaClinical depression or schizophrenia Substance AbuseSubstance Abuse Feelings of hopelessnessFeelings of hopelessness Severe anxiety, particularly with Severe anxiety, particularly with

depressiondepression Severe loss of interest in usual activitiesSevere loss of interest in usual activities Impaired thought processImpaired thought process ImpulsivityImpulsivity

Assessing Risk and Assessing Risk and Planning InterventionPlanning InterventionRiskRisk

LevelLevelSpecifiSpecifi

cc

PlanPlan

Risk Risk FactorsFactors

SeveritSeverityy

IntentIntent

InterveInterven.n.

LowLow NoNo FewFew NoneNone Safety PlanSafety Plan

Mod.Mod. VagueVague

Plan/low Plan/low lethallethal

IncreasedIncreased NoneNone Safety PlanSafety Plan

SevereSevere SpecificSpecific

lethal planlethal planIncreasedIncreased NoneNone Safety PlanSafety Plan

Remove Remove Lethal ItemsLethal Items

ExtremeExtreme Specific Specific lethal planlethal plan

IncreasedIncreased Intent to dieIntent to die Safety PlanSafety Plan

Remove Remove Lethal ItemsLethal Items

HospitalizeHospitalize

Commonalities of Commonalities of Suicide Suicide

(Schneiderman, 1985)(Schneiderman, 1985)1.1. purpose is to seek a solution. purpose is to seek a solution. 2.2. goal is the cessation of consciousness (not goal is the cessation of consciousness (not

death). death). 3.3. stimulus is intolerable psychological pain. stimulus is intolerable psychological pain. 4.4. stressor is frustrated psychological needs. stressor is frustrated psychological needs. 5.5. emotion is hopelessness-helplessness. emotion is hopelessness-helplessness. 6.6. cognitive state is ambivalence. cognitive state is ambivalence. 7.7. perceptual state is constriction. perceptual state is constriction. 8.8. action is egression. action is egression. 9.9. interpersonal act is communication of intention. interpersonal act is communication of intention. 10.10. consistency is with lifelong coping patterns. consistency is with lifelong coping patterns.

Clinical Considerations Clinical Considerations of Suicide Assessmentof Suicide Assessment

For those who are reluctant to For those who are reluctant to assess suicide:assess suicide:

Asking questions may feel Asking questions may feel intrusive but not asking has intrusive but not asking has dangerous consequencesdangerous consequences

A calm and genuinely concerned A calm and genuinely concerned approach is effectiveapproach is effective

Suicide:TreatmentSuicide:Treatment

Problem-solving Problem-solving Cognitive behavioral therapyCognitive behavioral therapy Coping skillsCoping skills Stress reductionStress reduction

Postpartum DepressionPostpartum Depression

BurdenBurden

In the United States, depression is the In the United States, depression is the leading cause of non-obstetric leading cause of non-obstetric hospitalizations among women aged 18-44.hospitalizations among women aged 18-44.

In the year 2000, 205,000 women aged 18-In the year 2000, 205,000 women aged 18-44 were discharged with a diagnosis of 44 were discharged with a diagnosis of depression.depression.

Seven percent of all hospitalizations among Seven percent of all hospitalizations among young women were for depression.young women were for depression.

Perinatal Depression: Perinatal Depression: PrevalencePrevalence

PregnancyPregnancy PostpartumPostpartumKumar & Robeson Kumar & Robeson 19841984

13.4%13.4% 14.9%14.9%

Watson & Elliott Watson & Elliott 19841984

9.4%9.4% 12.0%12.0%

O’Hara et al., 1984O’Hara et al., 1984 9.0%9.0% 12.0%12.0%

Cooper et al. 1988Cooper et al. 1988 6.0%6.0% 8.7%8.7%

O’Hara et al., 1990O’Hara et al., 1990 7.7%7.7% 10.4%10.4%

Evans et al., 2001Evans et al., 2001 13.6%13.6% 9.2%9.2%

Postpartum BluesPostpartum Blues

Most common, 50-Most common, 50-80%80%

Relatively briefRelatively brief– Few hours to several Few hours to several

days days Onset usually in first Onset usually in first

week to 10 days PPweek to 10 days PP Typically remit Typically remit

spontaneouslyspontaneously– May represent the May represent the

initial stages of initial stages of PPD/PPPPPD/PPP

Typical Blues Typical Blues SymptomsSymptomsTypical Blues Typical Blues SymptomsSymptoms Low MoodLow Mood Mood LabilityMood Lability InsomniaInsomnia

AnxietyAnxiety CryingCrying IrritabilityIrritability

Postpartum Postpartum PsychosisPsychosis

Rare: 1/1000 postpartum Rare: 1/1000 postpartum womenwomen

Hallucinations and/or Hallucinations and/or DelusionsDelusions

Risk Factors:Risk Factors: History Bipolar History Bipolar

Affective Affective Disorder/PsychosisDisorder/Psychosis

Family history of Family history of psychosispsychosis

Having first childHaving first child

Aggressive intervention Aggressive intervention absolutely necessaryabsolutely necessary

Postpartum Postpartum PsychosisPsychosis Postpartum Postpartum PsychosisPsychosis

Usually Begins Within 90 Days PostpartumUsually Begins Within 90 Days Postpartum Length is Quite VariableLength is Quite Variable Prevalence: 1/500 to 1/1000Prevalence: 1/500 to 1/1000 Family history of bipolar disorder 33/1000Family history of bipolar disorder 33/1000 Family history of postpartum psychosis Family history of postpartum psychosis

22/100022/1000 Personal history bipolar disorder: 1/2Personal history bipolar disorder: 1/2 Sequelae: Future Postpartum PsychosisSequelae: Future Postpartum Psychosis

Postpartum Postpartum DepressionDepression Not as mild or Not as mild or

transient as the transient as the bluesblues

Not as severely Not as severely disorienting as disorienting as psychosispsychosis

Range of severityRange of severity Often undetectedOften undetected

Postpartum Depression: Risk Postpartum Depression: Risk FactorsFactors Lower SES/unemploymentLower SES/unemployment Past depression or anxiety disorderPast depression or anxiety disorder Past history of alcohol abusePast history of alcohol abuse Stressful life-eventsStressful life-events Poor marital relationshipPoor marital relationship Inadequate social supportInadequate social support Child-care related stressorsChild-care related stressors African American ethnicityAfrican American ethnicity

Effects of Perinatal Effects of Perinatal Depression:Depression:An OverviewAn Overview Depression negatively effects:Depression negatively effects:

Mother’s ability to motherMother’s ability to mother Mother—infant relationshipMother—infant relationship Emotional and cognitive Emotional and cognitive

development of the childdevelopment of the child

Postpartum Depression:Postpartum Depression:Maternal AttitudesMaternal Attitudes

– Infants perceived to be more Infants perceived to be more bothersomebothersome

– Make harsh judgments of their infantsMake harsh judgments of their infants

– Feelings of guilt, resentment, and Feelings of guilt, resentment, and ambivalence toward childambivalence toward child

– Loss of affection toward childLoss of affection toward child

Postpartum Depression:Postpartum Depression:Maternal BehaviorsMaternal Behaviors

Gaze less at their infantsGaze less at their infants

Take longer to respond to infant’s utterancesTake longer to respond to infant’s utterances

Show fewer positive facial expressionsShow fewer positive facial expressions

Lack awareness of their infantsLack awareness of their infants

Increased risk for abusing childrenIncreased risk for abusing children

Postpartum Depression:Postpartum Depression:Maternal InteractionsMaternal Interactions

Flat affect, low activity level, and lack of Flat affect, low activity level, and lack of contingent respondingcontingent responding

OROR

Alternating disengagement and Alternating disengagement and intrusivenessintrusiveness

Effects of Maternal Effects of Maternal DepressionDepression

Infants- lowered Brazelton scores, Infants- lowered Brazelton scores, frequent looking away, fussinessfrequent looking away, fussiness

Toddlers- poorer cognitive development, Toddlers- poorer cognitive development, insecure attachmentinsecure attachment

Children- cognitive development of low Children- cognitive development of low ses boysses boys

Adolescents-higher cortisol levelsAdolescents-higher cortisol levels

What Can Be Done?What Can Be Done?

ROUTINE SCREENINGROUTINE SCREENING

REFERRAL TO TREATMENTREFERRAL TO TREATMENT

Why Screen for Why Screen for Perinatal Depression?Perinatal Depression?

Screening is associated with Screening is associated with increased detectionincreased detection

Georgiopoulos et al., 1999, 2001Georgiopoulos et al., 1999, 2001– EPDS screening resulted in increased EPDS screening resulted in increased

chart-based diagnosis of PPD from chart-based diagnosis of PPD from 3.7% to 10.7% after one year of 3.7% to 10.7% after one year of universal screening – Rochester, MNuniversal screening – Rochester, MN

Barriers to DetectionBarriers to Detection

Women will present themselves as Women will present themselves as well as they are ashamed and well as they are ashamed and embarrassed to admit that they embarrassed to admit that they are not feeling happyare not feeling happy

Media images contribute to this Media images contribute to this phenomenaphenomena

Barriers to DetectionBarriers to Detection

Women will present themselves Women will present themselves as well as they are ashamed and as well as they are ashamed and embarrassed to admit that they embarrassed to admit that they are not feeling happyare not feeling happy– Tom Cruise: Snap out of it mentalityTom Cruise: Snap out of it mentality

Media images contribute to this Media images contribute to this phenomenaphenomena

Barriers to Detection Barriers to Detection (cont)(cont) Lack of knowledge about range of Lack of knowledge about range of

postpartum disorderspostpartum disorders

They don’t want to be identified with They don’t want to be identified with Andrea YeatsAndrea Yeats

May genuinely feel better when you May genuinely feel better when you see them (they got dressed, out of see them (they got dressed, out of house, lots of attention, not isolated)house, lots of attention, not isolated)

““I Was Depressed But I Was Depressed But Didn’t Know It.”Didn’t Know It.”

Commonalities in the Experience of Commonalities in the Experience of Non-depressed and Depressed Non-depressed and Depressed Pregnant and Postpartum WomenPregnant and Postpartum Women

Changes in appetiteChanges in appetite Changes in weightChanges in weight Sleep disruption/insomniaSleep disruption/insomnia Fatigue/low energyFatigue/low energy Changes in libidoChanges in libido

What is Required for What is Required for Effective Screening?Effective Screening?What to do with a positive screen?What to do with a positive screen?

1.1. Implement or refer for diagnostic Implement or refer for diagnostic assessmentassessment

Arrange for treatmentArrange for treatment1.1. Antidepressant medicationAntidepressant medication

2.2. Psychotherapy (individual or group)Psychotherapy (individual or group)

Arrange for follow-upArrange for follow-up