Mood disorders - summary of chapter 5 of Abnormal Psychology by Kring, Davison, Neale & Johnson (12th edition)

Clinical psychology
Chapter 5
Mood disorders

Mood disorders involve disabling disturbances in emotion.

Clinical descriptions and epidemiology of mood disorders

The DSM-5 recognizes two broad types of mood disorders:

• Those that involve only depressive symptoms
• Those that involve manic symptoms

Depressive disorders

The cardinal symptoms of depression include profound sadness and/or an inability to experience pleasure.

Physical symptoms of depression are also common

• Fatigue and low energy
• Physical aches and pains
  These symptoms can be profound enough to convince afflicted persons that they must be suffering from some serious medical condition, even though the symptoms have no apparent physical cause.
• Although people with depression typically feel exhausted, they may find it hard to fall asleep and may wake up frequently.
  Other people sleep throughout the day.
• They may find that foot tasted bland or that their appetite is gone, or that may experience an increase in appetite.
• Sexual interest disappears
• Some may find their limbs feel heavy
• Psychomotor retardation: thoughts and movements may slow
• Psychomotor agitation: not being able to sit still

Social withdrawal is common.

Major depressive disorder

Major depressive disorder (MDD)

• An episodic disorder: symptoms tend to be present for a period of time and then clear.
  Even though periods tend to dissipate over time, an untreated episode may stretch for 5 months or even longer.
  For a small percentage of people, the depression becomes chronic.
• Major depressive episodes tend to recur, once a given episode clears, a person is likely to experience another episode.
  The average number of episodes is about four. With every new episode that a person experiences, his or her risk for experiencing another episode goes up by 16 percent.

DSM-5 criteria

• Sad mood and loss of pleasure in usual activities
• At least five symptoms (counting sad mood and loss of pleasure)
  • Sleeping too much or too little
  • Psychomotor retardation or agitation
  • Weight loss or change in appetite
  • Loss of energy
  • Feelings of worthlessness or excessive guilt
  • Difficulty concentrating, thinking, or making decisions
  • Recurring thoughts of death or suicide
• Symptoms are present nearly every day, most of the day, for at least 2 weeks.
• Symptoms are distinct and more severe than a normative response to significant loss.

Persistent depressive disorder (Dysthymia)

People wit dysthymia are chronically depressed, more then half of the time for at least 2 years. They feel blue or derive little pleasures from usual activities and pastimes.

DSM-5 criteria for persistent depressive disorder (dysthymia)

• Depressed mood for most of the day more than half of the time for 2 years (or 1 year for children and adolescents).
• At least two of the following during that time:
  • Poor appetite or overeating
  • Sleeping too much or too little
  • Poor self-esteem
  • Low energy
  • Trouble concentrating or making decisions
  • Feelings of hopelessness
• The symptoms do not clear for more than 2 months at a time.

DSM-5 criteria for premenstrual dysphoric disorder

• A. in most menstrual cycles during the past year, at least five of the following symptoms from sections B and C were present in the final week before menses, improved within a few days of menses onset, and became minimal in the week after menses.
• B. At least 1 of the following symptoms
  • Affective lability
  • Irritability
  • Depressed mood, hopelessness, or self-depreciating thoughts
  • Anxiety
• C. At least 1 of the following symptoms
  • Diminished interest in usual activities
  • Difficulty concentrating
  • Lack of energy
  • Changes in appetite, overeating, or food craving
  • Sleeping too much or too little
  • Subjective sense of being overwhelmed or out of control
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating, or weight gain.
• Symptoms lead to significant distress or functional impairment
• Symptoms are not an exacerbation of another mood or anxiety disorder or personality disorder.
• Symptoms are confirmed with prospective daily ratings over two cycles
• Symptoms are present when oral contraceptives are not being taken.

DSM-5 criteria for disruptive mood dysregulation disorder

• Severe recurrent temper outbursts, including verbal or behavioral expressions of temper that are out of proportion in intensity or duration to the provocation
• Temper outbursts are inconsistent with developmental level
• The temper outbursts tend to occur at least three times per week
• Negative mood between temper outbursts is observable to others on most days
• These symptoms have been present for at least 12 months and do not clear for more than 3 months at a time.
• Temper outbursts and negative mood are present in at least two settings and are severe in at least one setting
• Age 6 or older (or equivalent developmental level)
• Onset before age 10
• There has never been a distinct period lasting more than 1 day during which elevated mood and at least three other manic symptoms were present
• The behaviors do not occur exclusively during the course of major depressive disorder and are not better accounted for by another mental disorder
• This diagnosis can not coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorders.

Epidemiology and consequences of depressive disorders

MMD is one of the most prevalent psychiatric disorders.
Persistent depressive disorder appears to be rarer than MDD.

• MMD is twice as common among women than among men.
• Socioecomomic status also matters. MDD is three times as common among people who are impoverished compared to those who are not.

The prevalence of depression varies across cultures.
Symptoms of depression also show some cross-cultural variation, probably resulting from differences in cultural standards regarding acceptable expressions of emotional distress.
These symptom differences do not appear to be major enough to explain the differing rates of depression across countries.

Differences between countries in rates of depression may be fairly complex.

• The distance form the equator. (winter depression)
• Fish consumption
• Cultural and economic factors

In most countries, the prevalence of MDD increased steadily during the mid to late twentieth century.
At the same time, the age onset decreased. The median age of onset is now the late teens to early 20s.

• Social changes that have occurred over the past 100 years.

Beyond the prevalence rates, the symptoms of depression vary somewhat across the life span.

Both MDD and persistent depressive disorder are often associated, or comorbid, with other psychological problems.

Depression has many serious consequences

• Suicide is a real risk
• Causes of disability
• Higher risk of other health problems

Bipolar disorders

DSM-5 recognizes three forms of bipolar disorders:

• Bipolar I disorder
• Gipolar II disorder
• Cyclothymic disorder

Manic symptoms are the defining feature of each of these disorders.
The bipolar disorders are differentiated by how severe and long-lasting the manic symptoms are.

The disorders are labeled ‘bipolar’ because most people who experience mania will also experience depression during their lifetime.
An episode of depression is not required for a diagnoses of bipolar I, but it is required for a diagnoses of bipolar II disorder.

Mania: a state of intense elation or irritability, accompanied by other symptoms shown in the diagnostic criteria.
During manic episodes, people will act and think in ways that are highly unusual compared with their typical selves.
Flight of ideas.

Hypomania: less extreme than mania.
Mania involves significant impairment, hypomania does not.
Hypomania involves a change in functioning that dos not cause serious problems.
The person with hypomania may feel more social, flirtatious, energized, and productive.

DSM-5 criteria for manic and hypomanic episodes

• Distinctly elevated or irritable mood.
• Abnormally increased energy or activity.
• At least three of the following are noticeably changes from baseline (four if mood is irritable):
  • Increase in goal-directed activity or psychomotor agitation
  • Unusual talkativeness, rapid speech
  • Flight of ideas or subjective impression that thoughts are racing
  • Decreased need for sleep
  • Increased self-esteem: belief that one has special talents, powers, or abilities
  • Distractibility: attention easily diverted
  • Excessive involvement in activities that are likely to have painful consequences
  • Symptoms are present most of the day, nearly every day
• For a manic episode:
  • Symptoms least for 1 week, require hospitalization, or include psychosis
  • Symptoms cause significant distress or functional impairment
• For hypomanic episode:
  • Symptoms last at least 4 days
  • Clear changes in functioning are observable to others, bu impairment is not marked
  • No psychotic symptoms are present

Bipolar I disorder

A single episode of mania during the course of a person’s life.
A person who is diagnosed may or may not be experiencing curring symptoms of mania.
Even someone who experienced only 1 week of manic symptoms years ago is still diagnosed with bipolar I disorder.
Bipolar episodes tend to recur.

Bipolar II disorder

To be diagnosed with bipolar II disorder, a person must have experienced at least one major depressive episode and at least one episode of hypomania.

Cyclothymic disorder

Also called cyclothymia.
A chronic mood disorder.
The symptoms must be present for at least 2 years among adults.
In cyclothymic disorder, the person has frequent but mild symptoms of depression, alternating with mild symptoms of mania.
Although the symptoms do not reach the severity of full-blown hypomanic or depressive episodes, people with the disorder and those close to them typically notice the ups and downs.
During the lows, a person may be sad, feel inadequate, withdraw from people, and sleep for 10 hours a night.
During the highs, a person may be boisterous, overly confident, socially uninhibited and gregarious, and need little sleep.

DSM-5 criteria for Cyclothymic disorder

• For at least 2 years (1 year in children and adolescents)
  • Numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode
  • Numerous periods with depressive symptoms that do not meet criteria for a major depressive episode
• The symptoms do not clear for more than 2 months at a time.
• Criteria for a major depressive manic, or hypomanic episode have never been met.
• Symptoms cause significant distress or functional impairment.

Epidemiology and consequences of bipolar disorder

Bipolar I disorder is much rarer than MDD.

Culture may shape tendencies to label behaviors as manic symptoms.

It is extremely hard to estimate the prevalence of milder forms of bipolar disorder, because some of the most commonly used diagnostic interviews are not reliable.

More than half of those with bipolar spectrum disorders report onset before age 25, but these conditions are being seen with increasing frequency among children and adolescents.
Bipolar occurs equally often in men and women, but women experience more episodes of depression than do men.

About two-third of people diagnosed with bipolar disorder meet diagnostic criteria for a cormorbid anxiety disorder, and more than a third report a history of substance use.

Bipolar I is among the most severe forms of mental illness.

• People with bipolar are unable to work about 25 percent of the time
• Suicide rates are high for both bipolar I and bipolar II disorders
• High risk for a range of other medical conditions

Subtypes of depressive disorders and bipolar disorders

The mood disorders are highly heterogeneous. People who have been diagnosed with the same disorder may show very different symptoms.
The DSM-5 deals with this by providing criteria for dividing MDD and bipolar disorders into a number of specifiers (subtypes), based on either specific symptoms or the pattern of symptoms over time.
Rapid cycling and seasonal specifiers: the overall pattern of episodes over time, whereas other specifiers describe the current episode of major depression or mania.

Melancholic is used only for episodes of depression.

The seasonal specifier of major depressive disorder has achieved a fair amount of support, but many of the other specifiers have not been well validated.

Etiology of mood disorders

No single cause can explain mood disorders.
A number of different factors combine to explain their onset.

Neurobiological factors in mood disorder

Genetic factors

Heritability of 37 percent for MDD.
About 37 percent of the variance in depression is explained in genes.

Bipolar is among the most heritable of disorders.
93 percent.
But, genetic models do not explain the timing of manic symptoms. Other factors likely serve as the immediate triggers of symptoms.

Genes may guide the way people regulate their emotions or respond to life stressors.
They may stet the stage for mood disorders to occur when other conditions are present.

Neurotransmitters

The absolute level of neurotransmitters is not important in mood disorders.

• Norepinephrine
• Dopamine
• Serotonin

Functioning of the dopamine might be lowered in depression.
Dopamine plays a major role in the sensitivity of the reward system in the brain, which is believed to guide pleasure, motivation, and energy in the context of opportunities to obtain rewards.

Dopamine receptors may be overly sensitive in bipolar disorder.

Tryptophan: the major precursor of serotonin.
Lower serotonin levels causes temporary depressive symptoms among people with a history of depression or a family history of depression.
This effect is not observed among people with no personal or family history of depression.
People who are vulnerable to depression may have less sensitive serotonin receptors, causing them to respond more dramatically to lower levels of serotonin.
Bipolar disorder may be related to diminished sensitivity of the serotonin receptors.

Brain-imaging studies

Two different types of brain-imaging studies are commonly used in research on mood disorders.

• Structural studies:
  Focus on whether a brain region is smaller or larger among people with a disorder
• Functional activation studies:
  Focus on whether there is a change in the activity of a brain region.

Episodes of MDD are associated with changes in may of the brain systems that are involved in experiencing and regulating emotion.
Four primary brain structures that have been most studied in depression

• The amygdala
• The subgenual anterior cingulate
• The hippocampus
• The dorsolateral prefrontal cortex

The amygdala

• Helps assess how emotionally important a stimulus is
  Amygdala hyperreactivity to emotional stimuli in depression might be part of the vulnerability to depression rather than just the aftermath of being depressed.

The subgenual anterior cingulate, the hippocampus, and the dorsolateral prefrontal cortex

• Particularly important in emotion regulation
  MDD is associated with greater activation of the subgenual anterior cingulate.
• People with depression demonstrate diminished activation of the hippocampus during exposure to emotional stimuli and of the dorsolateral prefrontal cortex when asked to regulate their emotions.
  Difficulty activating these regions is believe to interfere with effective emotion regulation.

Theory

• The overactivity in the amygdala during depression causes oversensitivity to emotionally relevant stimuli. At the same time, systems involved in regulating emotions are compromised.

Many of the brain structures implicated in MDD also appear to be involved in bipolar disorder.

• Bipolar I disorder is associated with elevated responsiveness in the amygdala, increased activity of the anterior cingulate during emotion regulation tasks, and diminished activity of the hippocampus and dorsolateral prefrontal cortex.

MDD and bipolar disorder might be differentiated by changes in the way that neurons throughout the brain function.
People with bipolar disorder often have deficits in the membranes of their neurons.
These deficits seem to operate across the brain, and they influence how readily neurons can be activated.
These cellular membrane deficits are not seen in people with MDD.

Protein kinase C activity appears to be abnormally high among people with mania.

The neuroendorcrine system: cortisol dysregulation

The HPA axis, the biological system that manages reactivity to stress, may be overly reactive among people with MDD, and the amygdala sends signals that activate the HPA axis.
The HPA axis triggers the release of cortisol, the main stress hormone
Cortisol is secreted at times of stress and increases activity of the immune system to help the body prepare for threats.

Various findings link depression to high cortisol levels.
The system does not seem to respond well to biological signals to decrease cortisol levels.
For those with MDD, dexamethasone does not suppress cortisol secretion, particularly among those with psychotic symptoms of depression.
Although cortisol helps mobilize beneficial short-term stress responses, prolonged high levels of cortisol can cause harm to body systems.

Like people with MDD, people with bipolar disorder fail to demonstrate the typical suppression of cortisol after the dex/CRH test.
This suggests that bipolar is also characterized by a poorly regulated cortisol system.
Like those with MDD, people with bipolar disorder who continue to show abnormal responses to cortisol challenge tests after their episode clears are at high risk for more episodes in the future.

Both bipolar disorder and MDD are characterized by problems in the regulation of cortisol levels.
Bysregulation in cortisol levels also predicts a worse course of illness for bipolar disorder and MDD.

Social factors in depression: life events and interpersonal difficulties

Neurobiological factors may be diatheses that increase risk for mood disorders in the context of other triggers or stressors.

The role of stressful life events in triggering episodes of depression is well established.
Life events typically happen before the depressive episode begins.
It remains possible that some life events are caused by early symptoms of depression that have not yet been developed into a full-blown disorder.

Stress can cause major depressive disorder
Common events

• Loss
• Certain types of life events, such as those involving loss and humiliation
  Many people with depression report that they had been experiencing long-term chronic stressors before the depression.
  Life events appear to be particularly important in the first episode of depression but less likely to be involved in later episodes.

Diathesis-stress models: models that consider both preexisting vulnerabilities (diatheses) and stressors.
Diatheses could be biological, social, or psychological.

Expressed emotion (EE): a family’s member’s critical or hostile comments toward or emotional overinvolvement with the person with depression.
High EE strongly predicts relapse in depression.

Psychological factors in depression

Personality and cognitive theories describe different diatheses that might increase the risk of responding to negative life events with a depressive episode.

Neuroticism

Neuroticism: a personality trait that involves the tendency to react to events with greater-than-average negative affect.
Predicts the onset of depression.
Neuroticism explains at least part of the genetic vulnerability to depression.
Neuroticism is associated with anxiety as well as dysthymia.

Cognitive theories

In cognitive theories, negative thoughts and beliefs are seen as major causes of depression.

• Pesimistic and self-critical thoughts can torture the person with depression.

Beck’s theory
Depression is associated wit ha negative trait: negative views of the self, the world, and the future.
According to this model, in childhood, people with depression acquired negative schema through experiences such as loss of a parent, the social rejection of peers, or the depressive attitude of a parent.
Schemas: underlying set of beliefs that operate inside of a person’s awareness to shape the way a person makes sense of his or her experiences.
The negative schema is activated whenever a person encounters situations similar to those that originally caused the schema to form.
Once activated, negative schemas are believed to cause cognitive biases.

Hopelessness theory
The most important trigger of depression is hopelessness, which is defined as an expectation that

• Desirable outcomes will not occur
• The person has no responses available to change this situation
  Within this model, hopelessness is hypothesized to contribute to only one type of depression (hopelessness depression).
  Hopelessness is believed to be triggered by life events that have important consequences for the person and/or the person’s self-evaluations.
• The model places emphasis on two key dimensions of attributions
  • Stable (permanent) versus unstable (temporary)
  • Global (relevant to many life domains) versus specific (limited to one area)
• People whose attributional style leads them to believe that negative life events are due to stable and global causes are likely to become hopeless, and this hopelessness will set the stage for depression.

Rumination theory
A specific way of thinking called rumination may increase the risk of depression.
Rumination: a tendency to repetitively dwell on sad experiences and thoughts, or to chew on material again and again.

Fitting together the etiological factors in depressive disorders

Some people seem ti inherit a propensity for a weaker serotonin system, which is then expressed as a greater likelihood to experience depression after a severe stressor.
Genetic vulnerability could set the stage for depressive disorder after major negative life events.
A polymorphism in the serotonin transporter gene has also been related to elevated activity of the amygdala.

Social and psychological factors in bipolar disorder

Most people who experience a manic episode during their life will also experience a major depressive episode, but not everyone will.

Depression is bipolar disorder

The triggers of depressive episodes in bipolar disorder appear similar to the triggers of major depressive episodes.

• Negative life events appear important in precipitating depressive episodes in bipolar disorder.
• Neuroticism
• Negative cognitive styles
• Expressed emotion
• Lack of social support

Predictors of mania

Two types of factors have been found to predict increases in manic symptoms over time

• Reward sensitivity
  People with bipolar disorder describe themselves as highly responsive to rewards
• Sleep deprivation
  Mania is intricately tied to disruptions in sleep and circadian (daily) rhythms.

Just as sleep depriviations can trigger manic symptoms, protecting sleep can help reduce symptoms of bipolar disorder.

Treatment of mood disorders

Psychological treatment of depression

Interpersonal psychotherapy

Interpersonal psychotherapy (IPT)
Build in the idea that depression is closely tied to interpersonal problems.
The core of therapy is to examine major interpersonal problems, such as role transitions, interpersonal conflicts, bereavement, and interpersonal isolation.
Typically, the therapist and the patient focus on one or two such issues, with the goal of helping the person identify his or her feelings about these issues, make important decisions, and make changes to resolve problems related to these issues.

IPT is typically brief
Techniques include discussing interpersonal problems, exploring negative feelings and encouraging their expression, improving both verbal and nonverbal communications, problem solving, and suggesting new and more satisfying modes of behavior.

IPT is effective in relieving MDD and it prevents relapse when continued after recovery.
IPT has also been found to be effective in the treatment of dysthymia.

Cognitive therapy

Cognitive therapy (CT)
Aimed at altering maladaptive thought patterns.
The therapist tries to help the person with depression to change his or her opinions about the self.
The therapist also teaches the person to monitor self-talk and the identify thought patterns that contribute to depression.
The therapist then teaches the person to challenge negative beliefs and to learn strategies that promote making realistic and positive assumptions.
Often, the client is asked to monitor their thoughts each day and to practice challenging overly negative thoughts.

Behavioral activation (BA)
People are encouraged to engage in pleasant activities that might bolster positive thoughts about one’s self and life.

Cognitive therapy is effective for relieving the symptoms of MDD.
With modifications, CT is promising in the treatment of dysthemia.
The strategies that clients learn in CT help diminish the risk of relapse even after therapy ends.

Computer-administered versions of CT have developed.
Typically, these interventions include at least brief contact with a therapist to guide the initial assessment, to answer questions, and to provide support and encouragement with the homework.
Computer-based programs have varied in effectiveness. It is important to ensure that consumers gain access to well-tested versions of computerized CT.

Mindfulnes-based cognitive therapy (MBCT)
Focuses on relapse prevention after successful treatment or recurrent episodes of major depression.
MBCT is based on the assumption that a person becomes vulnerable to relapse because of repeated associations between sad mood and patterns of self-devaluative, hopeless thinking during major depressive episodes. As a result, when people who have recovered from depression become sad, they begin to think as negatively as they had when they were severely depressed. These reactivated patterns of thinking turn intensify the sadness.
In people with a history of major depression, sadness is more likely to escalate, which may contribute to the onset of new episodes of depression.
The goal of MBCT is to teach people to recognize when they start to become depressed and to try adopting what can be called a ‘decentered’ perspective, viewing their thoughts merely as ‘mental events’ rather than as core aspects of the self or as accurate reflectations of reality.

MBCT is more effective than ‘treatment as usual’ in reducing the risk of relapse among people with three or more previous major depressive episodes.
MBCT does not appear to protect against relapse among people with only one or two previous major depressive episodes.

Behavioral activation (BA) therapy

The goal of BA is to increase participation in positively reinforcing activities so as to disrupt the spiral of depression, withdrawal, and avoidance.
Findings suggest that the BA component of CT performs as well as the full package does in relieving MDD and preventing relapse over a 2-year follow-up period.
Group versions of behavioral therapy also appear to be effective.

Behavioral couples therapy

Depression is often tied to relationship problems.
Researchers work with both members of a couple to improve communication and relationship satisfaction.
When a person with depression is also experiencing marital distress, behavioral couples therapy is as effective in relieving depression as individual CT or antidepressant medication.
Marital therapy has the advantage of relieving relationship distress.

Psychological treatment of bipolar disorder

Medication is a necessary part of treatment for bipolar disorder, but psychological treatments can supplement medications to help address many of its associated social and psychological problems.
These psychotherapies can also help reduce depressive symptoms in bipolar disorder.

Psychoeducational approaches: typically help people learn about the symptoms of the disorder, the expected time course of symptoms, the biological and psychological triggers for symptoms, and treatment strategies.
Careful education about bipolar disorder can help people adhere to treatment with medications.
Beyond helping people be more consistent about their medications, psychoeducational programs help people avoid hospitalization.

Several other types of therapy are designed to help build skills and reduce symptoms for those with bipolar disorder.

• Both CT and family-focused therapy (FFT) have received particularly strong support.
  CT draws on many of the types of techniques that are used in depressive disorder, with some additional content designed to address the early signs of manic episodes.
  FFT aims to educate the family about the illness, enhance family communication, and develop problem-solving skills.

Biological treatments of mood disorders

Electroconvulsive therapy for depression

Electroconvulsive therapy (ECT)
ECT is only used to treat MDD that has not responded to medication.
ECT entails deliberately inducing a momentary seizure and unconsciousness by passing 70- to 130- volt current trough the patients brain.
Unilateral ECT, in which the current passes only through the nondominant cerebral hemisphere is often used.
The patient is given a muscle relaxant before the current is applied.
The patients awakes a few minutes later remembering nothing about the treatment.
Typically, patients receive between 6 and 12 treatments, spaced several days apart.

ECT is more powerful than anitdepressant medications for the treatment of depression, particularly when psychotic features are present, even though we don’t know why it works.
People undergoing ECT face some risks for short-term confusion and memory loss.
It is fairly common for patients to have no memory of the period during which they received ECT and sometimes for the weeks surrounding the procedure.
Unilateral ECT produces fewer cognitive side effects than bilateral ECT does.
unilateral is associated with deficits in cognitive functioning 6 months after treatment.

Medications for depressive disorders

Drugs are most commonly used for depressive disorders.
Three major categories of antidepressant drugs

• Monoamine oxidase inhibitors (MAOIs)
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors

Antidepressants are effective for those with severe depression, but not for those with mild depression.

Although the various antidepressants hasten recovery form an episode of depression, relapse is common after the drugs are withdrawn.

Research comparing treatments for major depressive disorder

Combining psychotherapy and antidepressant medication bolsters the odds of recovery by more than 10 to 20 percent above either psychotherapy or medications alone for most people with depression.
Each treatment offers unique advantages.

CT is as effective as antidepressant medication for severe depression, and both treatments are more effective as an placebo.
CT has two advantages

• It is less expensive
• Over the long term it helped protect against relapse once treatment has finished

Medications for bipolar disorder

Medications that reduce manic symptoms are called mood-stabilizing medications.

• Lithium was the first mood stabilizer identified.
  Lithium has to be prescribed and used very carefully. Lithium levels that are to high are toxic.
  Patients taking lithium must have regular blood tests.
  It is recommended that lithium be used continually for the person’s entire life.

Two classes of medications other than lithium

• Anticonvulsant (antiseizure)
• Antipsychotic
  For people who are unable to tolerate lithium’s side effects.

Unfortunately, all these medications have serious side effects.

The mood-stabilizing medications used to treat mania also help relieve depression.
But many people continue to experience depression even after taking mood-stabilizing medication like lithium. For these people, antidepressant medication is often added to the regimen.

• It is not clear whether antidepressants actually help reduce depression among people who are already taken a mood stabilizer.
• Among people with bipolar disorder, antidepressants are related to a modest increase in the risk of a manic episode if taken without a mood stabilizer.

Depression and primary care

About half of all antidepressants are written by primary care physicians.

A final note on treatment

Antidepressant medication and ECT both stimulate growth of neurons in the hippocampus in rats.

Suicide

Suicide ideation: thoughts about killing oneself
Suicide attempts: behavior intended to kill oneself
Suicide: death from deliberate self-injury
Nonsuicidal self-injury: behaviors intended to injure oneself without intend to kill oneself.

Epidemiology of suicide and suicide attempts

Suicide rates may be grossly underestimated because some deaths are ambiguous.

• Worldwide, about 9 percent of people report suicidal ideation at least once in their lives, and 2,5 percent have made at least one suicide attempt.
• Men are four times more likely than women to kill themselves
• Women are more likely than men are to make suicide attempts that do not result in death
• Suicide rate increases in old age.
• Being divorced or widowed elevates suicide risk four- or fivefold.

Models of suicide

Psychological disorders

Many persons with mood disorders have suicidal thoughts and some engage in suicidal behaviors.
More than half of those who try to kill themselves are depressed at time of the act.
As many as 90 percent of people who attempt to suicide are suffering from a mental illness.
Suicides are most likely when a person is experiencing comorbid depression.

Most people with mental illnesses do not die from suicide.

Neurobiological models

Heritability is about 48 percent for suicide attempts.
There is a connection between serotonin and suicide.
Serotonin dysfunction may increase the risk of violent suicide.

Social factors

Economic ans social events have been shown to influence suicide rates.
Social factors that are more directly relevant to the individual are also powerful predictors of suicidality.

Psychological models

Suicide may have many different meanings
The psychological variables involved in suicide vary across people.

• Suicide relates to poor problem solving.
• Hopelessness is strongly tied to suicidality
  Among the people who are experiencing suicidal thoughts, people who are more impulsive are more likely to attempt suicide or to die from suicide.

Positive qualities may motivate a person to live and help a clinician build a case for choosing life.
People with more reasons to live tend to be less suicidal.

Preventing suicide

Giving a person permission to talk about suicide may relive a sense of isolation.
Most people are ambivalent about their suicidal thoughts, and they will communicate their intentions in some way.

Treating the associated psychological disorder

One approach to suicide prevention builds on our knowledge that most people who kill themselves are suffering from a psychological disorder.

Treating suicidality directly

Cognitive behavioral approaches appear to be the most promising therapies for reducing suicidality.
They also reduce suicidal ideation.

Cognitive behavioral treatments include a set of strategies to prevent suicide

• Therapists help clients understand the emotions and thoughts that trigger urges to commit suicide
• Therapists work with clients to challenge their negative thoughts and to provide new ways to tolerate emotional distress
• Help problem-solve about the life situations they are facing
  The goal is to improve problem solving and social support and thereby to reduce the feeling of hopelessness that often precede these episodes.