What is the relationship between mood disorders and suicide? - Chapter 6 (Abnormal Psychology)

Two different mood disorders are discussed below. Bipolar disorder is a disorder with periods of mania and periods of depression. Someone with a unipolar disorder only suffers from depression (not mania). Furthermore suicide is treated, or suicide.

Unipolar disorder

People with depression are completely confiscated by the disorder; depression affects the emotions, body functions, behaviours and thoughts of man.

The most important emotional symptoms in someone with a unipolar disorder are the sadness and the loss of all interest in life, which is referred to by the term anhedonia.

Many have also in people with depression body functions changed. These are changes in appetite, sleep and activity. Some people with depression have very little appetite, whereas others, on the other hand, very much.

In their behavior , many depressed people show changes in their way of moving. For example, they move very slowly in everything they do. This is called psychomotor retardation . Many people feel that they have little energy and that they are constantly tired. A small part of the depressed people feels restless. These people have opposite symptoms: psychomotor agitation, in which people feel physically agitated, can not sit still and walk around aimlessly or fidget.

The cognitive symptoms of depression are all kinds of thoughts about, for example, hopelessness, shame and suicide. In serious cases, there are also delusions and hallucinations. Delusions are thoughts that have no basis in reality. Hallucinations are observations that someone has, who are not actually there.

Depression can take different forms. Major depressive disorder is a severe depression that lasts at least two weeks. The diagnosis requires that someone feels depressed or has a loss of interest in daily activities. In addition, at least four other symptoms of depression must be present. According to the DSM-IV, there are two types of unipolar depression: major depression and dysthymic disorder. The difference between these two disorders is that a major depression is of shorter duration, but very intense. Dysthymic disorder is a chronic form of depression, which lasts for at least one year in adolescents and two years in adults. This depression can be less severe a major depressive disorder. A person must have a depressed mood and his interest in life must be lost. In addition, there must be at least four other symptoms of depression for at least two weeks, involving a disruption of daily life. There are two types of major depressions: in the first type (major depression single occurrence) there is only one single depressive episode, while in the second type (major depression periodically) there are two or more episodes with at least two consecutive months without symptoms between the episodes. The DSM-V criteria contain the observation that a normal and expected depressive response to a negative event, such as a loss, should not be diagnosed as a major depressive disorder unless other symptoms such as worthlessness, suicidality and psychomotor retardation are present.

More chronic forms of depression have been reformulated in the DSM-V, and have now been named 'persistent depressive disorder' (formerly dysthymic disorder and chronic major depressive disorder). In a persistent depressive disorder there is a depressive mood that persists for at least two years. In children and adolescents there must be a depressive or irritated mood for at least one year. Furthermore, there must be two or more of the following symptoms:

The other variant of depression, a dysthymic disorder, lasts much longer, but is less intense. Some people suffer from a double depression. These people have a dysthymic disorder, with episodes of major depression. When they come out of such an episode, they fall back into dysthymia.

Symptoms of depression: 1. Little food or overeating. 2. Insomnia or sleeping too much. 3. Little energy or fatigue. 4. A low self-esteem. 5. Poor concentration and difficulty making decisions. 6. Feelings of hopelessness.

During this two-year period (or one year in adolescents), the depression should never be longer than two months in a row. People with persistent depressive disorder are more likely to have comorbidity of disorders, including anxiety disorders and substance abuse.

More than 70% of people with depression also have a different psychological disorder at a given time. The most common disorders in combination with depression are substance abuse, anxiety disorders and eating disorders. Sometimes depression can be a cause or consequence of another disorder.

There are different subtypes of depression.

1. Depression with anxious stress. People with this subtype have both anxiety symptoms and depressive symptoms.
2. Melancholy depression, here are mainly the physical symptoms present. Depression with mixed characteristics. People with this subtype meet the criteria for major depressive disorder, and at least three symptoms of mania, but do not meet all criteria for a manic episode. Depression with psychotic characteristics, people suffer from delusions and hallucinations during a depressive period.
3. Depression with melancholic characteristics. In particular, the physiological symptoms of depression are present.
4. Depression with psychotic characteristics. Here, people also experience illusions and hallucinations.
5. Depression with catatonic features, this involves strange behaviours associated with catatonia. One speaks of catatonia when different types of behavior are totally disturbed. These behaviours can vary from totally no movements to a very large amount of motor activity.
6. Atypical depression, a depression in which there is a collection of different symptoms;
7. Depression with peripartum begins. This diagnosis is given to women who have a major depressive episode during pregnancy or within four weeks after the birth of the child. Postnatal depression, a depression that occurs within 4 weeks of a child being born. It can also occur that a mother becomes manic during pregnancy or after having a child, then the disorder is called bipolar disorder with peripartum onset. Postnatal bipolar disorder. 30 percent of women who have a child suffer from postpartum blues, which means that they suffer from lability, crying and fatigue.
8. Winter depression, or seasonal affective disorder (SAD). People with SAD have a history of at least two years in which, for example, they were depressed in the winter, and not in the summer. It is also possible that people in those periods become manic. The diagnosis is then bipolar disorder with seasonal onset.
9. Premenstrual: a lot of stress before menstruation

Disruption disorder depression is the most common psychological disorder. 16 percent of all Americans experience a depressive episode somewhere in their lives. Depression is the most prevalent among young adults, after which the chance of depression decreases. Only after the age of 85 years can an increase be seen again.

The decrease in the prevalence of depression in the older adults, older than 65 years, can be explained by the fact that the diagnosis is more difficult in these people. This may be because older people are less likely to admit that they are depressed because of the norms and values ​​they hold. Also the depression in the elderly often coincides with a certain disease, so depression is overlooked when making the diagnosis. Depression is also more difficult to diagnose because older people often decline in cognition. It is then difficult to distinguish between a depressive disorder and the early stages of a cognitive disorder. There is also the possibility that there are indeed fewer depressed elderly people. There are two explanations for this. People who are depressed, or have a tendency to become depressed, simply become less old. Another explanation is that older adults develop better coping strategies, which makes them less likely to develop depression.

If a child suffers from depression, it can have a big effect on the rest of his life. Because the self-image is still developing strongly in a child, a period of depression can bring about a major change. Because depression also affects performance at school, it can affect the child's future in this way. In other areas too, depression reduces the chances of the child, for example due to a poorer development of social skills. In puberty there is a big increase in depression in girls, but not in boys. This is probably because boys generally appreciate the changes in their bodies better than girls do.

Depression can often be a recurring problem. After people are recovered from a depressive episode, people remain susceptible to a relapse. 75% of people who have had a first depressive period will experience a depression later in life.

Bipolar disorder

Bipolar disorder is a disorder in which the symptoms of depression alternate with the symptoms of mania. The symptoms of depression have already been discussed above, here are the symptoms of mania.

People in a manic episode are elated, but that elation is often mixed with restlessness and irritation.

Symptoms of mania: 1. Higher self-esteem or sense of grandiosity. 2. Reduction of sleep. 3. More talking, or feeling more pressure to talk. 4. The feeling that ideas fly, or experience that thoughts race. 5. Be quickly distracted. 6. More targeted activity or psychomotor agitation. 7. Carry out more activities where chances are high for painful consequences.

People with bipolar I disorder have these symptoms and most of them also have to deal with severe periods of depression. People with bipolar II disorder also have severe periods of depression, but their manic periods are milder. This disorder is also called hypomania . The symptoms of mania are not serious enough to interfere with daily functioning, contain no hallucinations or illusions and last at least four days.

Like a dysthymic disorder, a cyclothymic disorder is a bipolar disorder that is less severe, but more chronic.

It is difficult to distinguish the excitement associated with mania in young people from the symptoms of ADHD, or from the symptoms of ODD. This is the reason that a new diagnosis has been added to the DSM-V to distinguish children with these outbursts of rage from children with a more classic bipolar disorder. This new diagnosis is the disruptive mood dysregulation disorder. A child must have at least three anger outbreaks per week for at least 12 months and in at least two settings in order to receive this diagnosis.

Bipolar disorder is much less common than a unipolar disorder, or depression. Between 1 and 2 percent of people suffer from this disorder in his or her life. Many people with this disorder have problems in daily life, such as at work or in their family. It is also often associated with other disorders, especially anxiety disorders and substance abuse.

There are indications that people with bipolar disorder are more creative. However, this advantage should not be exaggerated, because it does not outweigh the serious disadvantages of the disorder.

Biological theories about mood disorders

There are indications that genetic factors play a role in the development of depression and mania. Research into the family history of people with bipolar disorder shows that family members of the first degree (e.g. parents, brothers, sisters) have a two to three times greater chance of getting this disorder, compared to any other person. This seems like a lot, but if you have a father with bipolar disorder for example, then you only have a 5 to 10 percent chance of having the same disorder. For a unipolar disorder, the evidence for heredity is less than for bipolar disorder.

What is also interesting is that people with unipolar disorder have no greater chance of developing bipolar disorder than those without unipolar disorder. This indicates that there is a different genetic background for both disorders. Studies in twins have shown that for bipolar disorder the concordance (agreement) between identical (homozygous) twins is 60 percent and between non-identical twins (Heterozygous) is only 13 percent. This is a good indication of the genetic background of depression. The problem is that other studies showed a much lower agreement, so the evidence is not very strong. A large adoption study showed that biological brothers and sisters of someone with a mood disorder also had more frequent mood disorders, compared with brothers and sisters of people without mood disorders. The same also applied to the amount of suicides and suicide attempts.

Many biological theories about mood disorders mainly focus on the dysregulation of neurotransmitters. There are many neurotransmitters that may play a role in mood disorders, but it is mainly the monoamines that have to do with mania and depression. The monoamines are mainly norepinephrine, serotonin and, to a lesser extent, dopamine. These neurotransmitters are mainly found in places in the brain that serve to regulate sleep, appetite and emotion. It is thought that a surplus of these neurotransmitters causes mania and too few neurotransmitters for depression. A shortage of these neurotransmitters can have a number of causes. It is possible that too little of the substances is produced, it may also be that they are broken down too quickly, or they may be taken too quickly. An excess of neurotransmitters has the same causes, but vice versa (too much created, too slow to break down, or taken too slowly). A modern version of this monoamine theory states that something is wrong with the quantity or with the sensitivity of the receptors. In depression there are too few receptors or they are too sensitive. In bipolar disorder, it seems that the sensitivity and quantity of the receptors changes at the wrong times. Several CT, PET and MRI scans abnormalities in the brain were found within people with a mood disorder. Abnormalities were found in the following four parts of the brain:

1. Prefrontal cortex. This part focuses attention, short-term memory and solves problems. People with depression have less grey mass on the left and reduced metabolic activity. The left prefrontal cortex is mainly involved in motivation and purposeful behavior, which can explain the motivation problems in depression.

2. Anterior cingulate. Here the body reaction to stress occurs, emotional expression and social behavior. Different levels of activity are found, which is associated with problems in planning, attention and giving appropriate answers. It also has to do with the anhedonia that is found in a depression.

3. Hippocampus: memory and fear-related learning. A lower volume of the hippocampus and lower metabolic activity are found in a depression. Damage to the hippocampus can be caused by chronic activation of the physical stress reactions.

4. Amygdala: responsible for directing attention to emotional stimuli that are important to the person. In people with depression, this part is larger and more active, which can cause depressed people to focus more on aversive or emotionally exciting information.

The neuroendocrine system regulates a large number of hormones that are important for the body. These hormones help the body to respond to environmental stressors and regulate functions such as sleep and experiencing pleasure. Three important parts of the neuroendocrine system are the hypothalamus, the pituitary gland and the adrenal cortex, which work together in a feedback system. This system is called the HPA axis .

Normally, the HPA axis becomes more active when there is a stressor and then release hormones such as cortisol. When the stressor is gone, the HPA axis returns to an equilibrium situation.

In people with depression there is a chronic hyperactivity in the HPA axis, and it is difficult to return to a balance. One of the models about depression states that when people are exposed to chronic stress, they get a poorly developed HPA axis, which means that after a while they react too strongly to small stressors.

There is a discussion about whether the female hormonal cycle plays a role in depression. The main reason why people think that is because women are more likely to suffer from depression when they are in certain periods of their menstrual cycle, after they have given birth, or during their menopause. A special name had first been reserved for this form of depression in the DSM, but there is now a discussion going on whether this is necessary.

Psychological Theories

Depression often stems from negative events that cause a lot of stress. This can be, for example, after the loss of a job or after a divorce. The behavioral theory of depression states that stress in a person's life leads to depression, because of the stress less positive reinforcers. As a result, the person withdraws, resulting in even fewer positive reinforcers, after which a vicious circle arises. In addition, when people exhibit depressive behavior, they receive attention, thereby rewarding the depressive behavior.

Another theory, that of learned helplessness , states that depression usually comes from events that humans can not influence. Especially when these events often occur in someone's life, people start thinking that important things can not be changed, and they also lose motivation to change anything. The result of this is very similar to the symptoms of depression. The learned helplessness model originated from research in animals, but it also turned out to be applicable to people. People who are depressed often focus on how tired they feel, how hopeless they are and the like. They only think about it, but do not try to change it. This is also very similar to learned helplessness. Some people do not have this tendency and will therefore get rid of their depression faster than people who show this behavior.

One of the first cognitive theories was that of Aaron Beck. He stated that depressive people view the world from a negative cognitive triad: they see themselves, the world and the future as negative. Depressed people tend to make wrong thinking steps: for example, they ignore positive events, come to conclusions without sufficient evidence and exaggerate negative things. Often these negative thoughts are so automatic that the person does not even realize that he thinks so.

The reformulated learned helplessness theory is another influential theory. It is an adaptation to behaviourist theory, to show how cognitive factors can influence the feeling of helplessness. The theory focuses on the cause-and-effect attributes that individuals make. These attributions are statements that someone gives for certain things that happen. If someone sees negative things as something that is stable (it can not change), internally (it is up to the person) and globally ('if it is here, then it is everywhere like that'), then the person will expect negative events that he can not do anything about will often occur in the future. This leads to learned helplessness in many areas of his life. As with behaviourist theory, proponents of this theory argue that learned helplessness has the same symptoms as depression.

A number of studies have been conducted into the realism of people with depression. It turns out that people with depression can estimate much better than other people how much control they have about certain things. People who are not depressed tend to overestimate their influence on things, whereas depressed people are much more realistic. This has led to the idea that it is not the depressed people who think wrong, but the people who are not depressed. This is also called depressed realism .

The ruminative response styles theory focuses more on the way of thinking than on the content of thinking. People who think this way try not to change the causes of their feelings, and continue to worry about their depression. People with this ruminative coping strategy have a greater chance of depression.

Furthermore, depressed people pay more attention to negative thinking and negative stimuli. Because of this they see the world in a negative light. Also depressive people store memories in a more general way.

Interpersonal Theories deal with the relationships between people and which roles people occupy in certain situations. Disturbances in the roles are seen as the biggest source of depression. One of these theories states that if children do not experience their parents as warm and trustworthy, they develop an insecure attachment (unsafe attachment). This attachment style lays the foundation for relationships with others in the future. If someone learns from a young age that dealing with people in a certain, negative way, he gets certain expectations from others, and will act accordingly. These expectations are called contingencies or self-worth. These expectations are wrong, in the same way as in Aaron Beck's theory.

According to the interpersonal theories, people who are insecure in their relationships are constantly in need of confirmation (excessive reassurance seeking). At a given moment the environment gets tired of it, with the result that the person feels rejected and continues to slide off.

Another theory states that women base their self-image on the relationships they have with others. As a result, they are more likely to become depressed than men.

Social perspectives

The number of people with depression varies from generation to generation. At the beginning of the chapter a number of explanations have been mentioned above, now follows a statement from sociology. This statement uses the term cohort effect. That is the phenomenon that people in a certain period in history had a different chance of a certain disorder than people in a different period. These differences are due to the differences in culture between certain periods. Proponents of this theory say that people who were born recently are more likely to have depression because of the rapid changes in culture that started in the sixties, including the disintegration of the family as a stable basis in society. Another explanation is that people nowadays have higher expectations of themselves than people in the past and that they can not live up to these expectations, making them more depressed.

An important factor that determines depression is social status. This is a possible explanation for the fact that women are more likely to have depression than men (women generally have a lower social status than men). Men also have a different way of coping with stress than women. Men deny that they have stress and are more likely to drink alcohol, while women start to worry about their feelings and problems. As a result, men develop disorders such as alcohol abuse, while women are more likely to suffer from depression because of their tendency to worry. Social relationships are more important for women than for men. This can give them support when they need it, but because of this women also have a greater chance of depression if bad things happen to others or when they have a conflict with another.

There are also cross-cultural differences. Cultures with a lot of poverty, unemployment and discrimination have more depressive people.

Theories about bipolar disorder

Bipolar disorder is strongly linked to genetic factors. A twin study shows that 45-75% of the disorder is caused by genetic factors. Bipolar disorder also involves brain abnormalities. There is a difference in the structure of the brain in the amygdala and the prefrontal cortex. Part of the structure of the basal ganglia, the striatum, influences the processing of environmental factors. This does not work in a normal way in people with bipolar disorder. They are often oversensitive to rewarding environmental factors. Due to an error in the prefrontal cortex circuit to the striatum, people with bipolar disorder often have inflexible reactions to rewards. During a manic period they are excessively seeking rewards, while they are insensitive to rewards during a depressive period.

There are also abnormalities in the white mass of the brain, which connects the structures in the brain and transmitters. This is particularly the case in the prefrontal cortex, which means that the prefrontal cortex does not communicate well with other areas of the brain and can not properly control other areas of the brain. This leads to disorganized emotions and extreme behaviours.

People with bipolar disorder are more sensitive to rewards. Dysregulation of the dopamine system contributes to bipolar disorder. Higher levels of dopamine are associated with a greater tendency to seek rewards, while low levels are associated with insensitivity to rewards.

A psychosocial factor is stress. Stressful events trigger a new episode. If your body suddenly changes, for example in the form of different sleep or eating behavior, a relapse can easily occur. Significant changes in the daily routine can also trigger a new episode.

Biological treatments of mood disorders

In general, medication is prescribed for a mood disorder. Alternative biological treatments include electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vague nerve stimulation and deep brain stimulation (DBS). People with seasonal affective disorder (SAD) often benefit from light therapy.

Changes in the state of mind of people who use medication often only occur after a number of weeks. This may indicate that these drugs have slow effects on intracellular processes in the neurotransmitter systems and on the actions of genes that regulate neurotransmission, the limbic system and the stress response. Medications work better in severe depression than in mild or moderate depressions. Stopping medication in the first six to nine months after the symptoms are over seems to double the risk of a relapse in case of severe depression. People with bipolar disorder often take antidepressants continuously to prevent depression in a depression.

SSRIs (Selective Serotonin Reuptake Inhibitors) are often used to treat depressive symptoms. They are not more effective than other available antidepressants, but they have much less serious side effects and are safer when an overdose is taken. This is because they only work on serotonin and not on other neurotransmitters. In addition, they also have positive effects on a wide range of symptoms that often occur together with depression, such as anxiety, eating disorders and impulsivity. They also have the advantage that they start to work faster and that people take an overdose much less quickly than with other antidepressants. SNRIs (Selective, Serotonin-Norepinephrine Reuptake Inhibitors) have been developed to act on serotonin at norepinephrine levels in addition to serotonin, preventing them from relapse to depression much better than SSRIs. They do have slightly more side effects.

Bupropion works differently than the medication described above. Bupropion works on the norepinephrine and dopamine systems. Bupropion seems to be especially effective in people who suffer from, for example, psychomotor retardation, anhedonia and hypersomnia.

Tricyclic antidepressants help to fight the symptoms of depression well. They do so by ensuring that serotonin and norepinephrine are not reabsorbed in the synapse after they have been released. These drugs are pretty effective, 60 to 85 percent of the patients who receive these drugs are well helped. The disadvantages of these drugs are the side effects and the fact that someone can get an overdose quickly, because of this these drugs are not often prescribed anymore.

Monoamine oxidase inhibitors (MAOIs) are drugs that inhibit the action of the enzyme MAO. MAO is an enzyme that breaks down the monoamine neurotransmitters after they are released. If this enzyme is inhibited, more neurotransmitter is available. MAOIs are worse than the tricyclic medicine. The effectiveness is the same, but the side effects are even worse. These drugs can cause damage to, for example, the liver, and cannot be used in a diet that contains the amino acid tyramine because it reacts with it.

For bipolar disorder, far fewer treatments have been developed than for depression. Until recently, lithium was the only way to treat manic depression, but nowadays a number of drugs have been added. In addition, people with bipolar disorder often take antidepressants to reduce the depressive episodes. They also often take atypical antipsychotics.

Lithium is a medicine that reduces the symptoms of mania, but not the depression that follows. Usually people also use lithium between the manic episodes to ensure that there is no relapse. Lithium probably works by stabilizing the serotonin and dopamine systems. There are a number of problems with the use of lithium. The first problem is that it varies from person to person how much a person needs. The second problem is that there is only a small difference between an effective and a lethal dose. This means that patients must be well supervised by their therapist. Also, the side effects of lithium are very extreme, and sometimes life-threatening.

The use of anticonvulsants, antipsychotics and calcium channel blockers offers alternatives to lithium. Anticonvulsants are also effective against mania, but it is not yet clear how effective. Antipsychotic drugs are discussed in a subsequent chapter, but it appears that they are also effective in treating mania, especially if the mania has psychotic characteristics. Calcium channel blockers also prove effective, but they do not yet know how they work.

Another way to treat depressed people is to use electroconvulsive therapy (ECT). It was once introduced as a treatment method for schizophrenia.

ECT consists of a series of treatments in which an electric shock is sent through a person's brain. Usually this only happens on the right side of the brain to prevent memory loss. The patients are put under anaesthesia beforehand and get muscle relaxants, because the shocks can compress muscles enormously and you might suffer after the treatment.

ECT is used in people who are severely depressed and can not be helped with other treatments. How ECT works is not yet clear. It could be that the electric shock causes the barrier between the bloodstream and brain (blood-brain-barrier) to become more permeable, which improves the effect of medication. It could also be that the synapses release acute neurotransmitters when there is a shock through the brain. ECT is controversial for various reasons. In fact, ECT can suffer memory loss. Another problem of ECT is that the chance of a relapse after stopping treatment is quite high: 85 percent of the patients treated fall back into depression. The last reason is that the idea of ​​an electric shock through your brain is simply a scary thought.

There are new methods for brain stimulation. The first is repetitive transcranial magnetic stimulation (rTMS). Patients are regularly exposed to high magnetic pulses that are focused on specific parts of the brain. In depression, this is especially the prefrontal cortex. The big advantage of this is that the only side effect is headaches. Another method is vague nerve stimulation (VNS). A part of the brain of the autonomic nervous system (the vague nerve) transports information from the head, the neck, the thorax and the abdomen to different parts of the brain (including the amygdala and the hypothalamus). In this treatment, the vague nerve is stimulated by a small electronic device that is implanted under the skin in the left chest wall. The VNS increases activity in the hypothalamus and amygdala, which has antidepressant effects. The last method is deep brain stimulation. Electrodes are implanted in different parts of the brain, which are then stimulated. They are attached to a pulse generator that is placed under the skin.

Light therapy is often used to remedy winter depression (SAD). With light therapy, people are exposed to bright light for several hours a day in the winter. Light therapy is a way to adjust the biorhythm. The biorhythm is regulated by all kinds of hormones and brain processes, but also depends on environmental factors such as light. How this form of therapy works is not entirely clear yet. It may be that the biorhythm changes because the production of the hormones is normalized. It is also possible that the extra light causes increased melatonin production, which in turn leads to an increase in dopamine and norepinephrine levels. Another theory says that light therapy influences serotonin levels.

Psychological treatments for mood disorders

Behavioral therapy is aimed at increasing the number of positive reinforcers and reducing aversive experiences by ensuring that the patient organizes his life better. This form of therapy usually takes quite a short time, about 12 weeks. The first phase of the therapy consists of a functional analysis that examines how the patient's circumstances and symptoms are related. For example, it asks when the patient feels the worst. This analysis shows where the therapy needs to focus. It also serves to show the patient that he can do something about his environment, which will reduce his depression. After the analysis, the therapist and the patient can use a number of strategies to help the patient. This way they can try to change the environment in which the patient feels depressed. What they can also try is to teach the patient new skills, such as social skills. Another strategy is to learn skills to improve the mood of the patient in stressful circumstances.

In cognitive behavioral therapy , behaviourist techniques to learn new skills are combined with cognitive techniques. There are two goals in this therapy: breaking through the negative thinking patterns, and helping to solve problems in the patient's life so that the patient has less reason to be depressed. Cognitive behavioral therapy is short-lived, just like behavioral therapy. In cognitive behavioral therapy, it is important that the patient takes an active role.

The first step in this therapy is to identify automatic thoughts. These are, for example, thoughts with which the person blames himself for something, while that is not necessary. The second step is to show the patient that there are other ways to think about things. The therapist does this by asking all kinds of questions, for example "is this the only way to think about the situation?". The third step in this therapy is to let the patient realize which deeper beliefs underlie his / her depression.

In interpersonal therapy , there are four types of problems that are addressed.

• First, there are people who are depressed because they have lost someone. This can be due to the death of someone, but also due to, for example, a divorce.
• The second problem that interpersonal therapy can do something about is the problems in the division of roles between people. For example, it may be that there is tension because two married people do not agree on who should take care of the children. In therapy, the therapist shows where the problems lie, and lets patients choose which concessions they want to make to solve the problem.
• The third problem is that of the role changes. If someone suddenly has to change roles, for example if a working woman suddenly has to take care of her children, then that can give tensions. A therapist can accompany someone in this.
• A final problem that an interpersonal therapist can help someone with is learning interpersonal skills. The lack of these skills can lead to depression because someone often has less strong social support.

Interpersonal and social rhythm therapy (ISRT) is a form of therapy that has been specially developed for people with bipolar disorder. ISRT combines techniques from interpersonal therapy with behavioral therapy techniques to ensure that patients maintain regular routines of eating, sleeping and activities in their daily lives. It also ensures stability in their personal relationships. Patients learn how stressors in their families and working relationships influence their mood, and they develop better strategies to cope with these stressors.

Family Focused Therapy (FFT) is also designed to reduce interpersonal stress in people with bipolar disorder, especially within the family context. Patients and their families receive education on what bipolar disorder is, and are trained in communication and problem-solving skills. Especially in adolescents this can be effective.

More and more prevention programs are being started to prevent depression. This is done because depression can have a devastating effect on people and society. The prevention programs mainly focus on groups that are particularly vulnerable to depression, such as adolescents.

The last decades have been comparing which therapy is most effective in different disorders. With depression, many types of therapy are all equally effective. Another outcome of these studies is that there is a large placebo effect. If someone develops a warm bond with his therapist, he will heal faster than if his relationship with the therapist is bad. The therapies are the same in effectiveness, but treatment with medication works faster. However, these treatments have a higher chance of relapse than psychological therapies.

In bipolar disorder, combining medication with a psychological treatment can ensure that patients continue to take their medications, making more patients completely better compared to treatment with lithium alone. Psychotherapy can help people with bipolar disorder to understand and accept that they need lithium, and it can help people deal with the impact the disorder has on their lives.

Defining suicide / suicide

Suicide (suicide) is deliberately depriving one's own life by causing damage to the body, or by poisoning or suffocation. The definition is easy, but suicide is often difficult to determine, because the termination of life can also be an accident. Suicide attempts sometimes result in death, but they may not succeed. Suicidal ideas or thoughts still have to be implemented, but usually it does not come that far.

Suicide figures

It is difficult to determine how many people die exactly because of suicide, among other things because of the stigma attached to suicide. It is also difficult to determine the figures, because it is difficult to determine exactly what a suicide is and what is not. Although the figures are probably too low, it appears that a lot of people are dying of suicide.

It would be logical that suicide is more common in women than in men, because they are more often depressed. That is not the case. It appears that women are more likely to attempt suicide, but that most attempts fail, while men are more likely to succeed in their suicide attempt. This is probably explained by the fact that men use more effective methods than women. Another explanation for this phenomenon is that if men do a suicide attempt, they are more confident of themselves and thus choose a more effective method. What should also be noted is that men use alcohol more often, and that alcohol use is a strong predictor of suicide.

In recent years, the number of suicides among children and adolescents has increased significantly. It often happens that parents and psychologists do not believe that a child can have suicidal thoughts, simply because a young child would not understand the concept of suicide. It appears that suicide is rare in younger children, but it certainly occurs. For adolescents, suicide is the third largest cause of death. That adolescents more often commit suicide than children can because many psychological disorders develop during adolescence. Another cause may be that adolescents can think better about things like suicide than children. It is also possible that adolescents have more opportunities to commit suicide.

The number of suicides increases among older people over the age of 85. The suicide is usually the result of no longer being able to process the loss of the partner or loved ones. Some commit suicide because they are sick.

Non-suicidal self-harm

Some people cut, burn, prick or try to damage their body in a different way without them wanting to die. This is especially true in adolescents. Such behavior is called non-suicidal self-injury (NSSI) or non-suicidal self-harm.

People who do NSSI have a greater chance of committing suicide. NSSI would regulate emotions and see blood would give them a sense of calm. It can also happen that they want to feel sorry for others or others want to hurt.

Explaining Suicide

About suicide is still a lot unknown because it is too rare to study it properly. Moreover, relatives often do not know all the information that may be relevant for an investigation into the motivation of the victim. Finally, most people who commit suicide do not leave a note. If a note is left, there is usually no clear reason why suicide was committed.

According to the sociological theory of Durkheim, three different types of suicide can be distinguished. Egoistic suicide is for example committed by someone who feels abandoned by others and no longer has social contacts. Anomic suicide is committed by someone who is disoriented, for example because someone loses his job after 20 years of service. Altruistic suicide is committed when someone thinks that he can help other people with it. The conclusion of this theory is that many suicides can be prevented if the society rejects suicide. In such a society, an individual will first try to solve his problems in other ways.

If two or more suicides are linked to each other, this is called a suicide cluster. This can occur, for example, if someone is suicidal at a school, and someone follows him or her a few days later in that behavior. It may also happen that more people commit suicide after a famous person has done so. There are several explanations for this phenomenon. Some scientists call it suicide contamination (suicide contagion). People somehow take over the suicidal thoughts of someone else. It may be that the person who has committed suicide is a role model for those who are left behind.

If a well-known person commits suicide, then suicide becomes more acceptable to people who have problems. The media attention is also an extra incentive to commit suicide.

Another explanation is that people enter into relationships with people who have the same problems as they do. For example, people who are outcasts tend to interact with each other at school. If someone commits suicide in such a group, then that is a negative event in the lives of the other members of that group, and they will be more unbalanced, which means they will commit suicide more quickly.

Psychological explanations

Freud said that suicide is an extreme expression of inward-looking anger. This anger is caused when the person is abandoned by someone, but can not be directed at the other person. That is why the anger focuses on the part of the ego that represents that other person. This anger can lead to suicide. According to this line of thinking, people who commit suicide are full of anger and hatred. Suicidal letters show that people who commit suicide feel guilty for what they do to others. Psychoanalysts say that this is because people can not directly express this hatred. This is a hard to test claim.

More than 90 percent of people who commit suicide probably had a psychological disorder. The diagnosis is often made only after the suicide. Through psychological autopsy reports, or through conversations with the relatives and diary, the psychological past is mapped.

Mood disorders, schizophrenia, anxiety disorders and alcohol abuse appear to increase the risk of suicide. The main reason for the suicide is to want to escape the unbearable pain.

Cognitive and behaviourist psychologists have a few things to say about suicide. People who commit suicide are generally desperate. Also these people generally think very rigidly (dichotomous). This rigidity ensures that they will not wait until the depression decreases. They think suicide is the only solution.

Biological explanations

Suicide is more common in certain families than in other families. This does not necessarily mean that suicide has a genetic basis, because it can be that members of a family get the same stressors to deal with. Research on twins has found an indication of the genetic basis of suicide.

A link has been found between suicide and low serotonin levels. This has been shown, for example, by doing autopsies on people who have committed suicide. Low serotonin levels were found to be associated with suicide. This was also the case when people were not depressed, while depression is also caused by low serotonin levels. Probably little serotonin causes impulsive and aggressive behavior, which increases the risk of suicide. This is evident from the fact that especially people who killed themselves violently had low serotonin levels.

Treatments and prevention

Someone who thinks a lot about suicide needs psychiatric help, and sometimes even a hospitalization. To prevent this, there are crisis intervention programs in communities that help people who are very suicidal. They provide care in the short term, but often refer people to specialists for long-term care. There are even suicide hotlines. They try to give people someone they can talk to and who understands their problems. Often the help of the family is also invoked.

An effective drug to reduce the risk of suicide in a suicidal person is lithium. SSRIs also reduce the risk of suicide because they stabilize the serotonin level. On the other hand, they increase the risk of suicide in children and adolescents. Antipsychotic drugs are used in psychotic patients to reduce their symptoms. If the symptoms become less, the suicidal behavior often also decreases.

Often the psychotherapies used to treat depression are also used to reduce the risk of suicide. Another therapy is dialectical behavior therapy. This is a therapy that teaches the patient different techniques, such as techniques to deal with negative emotions and to control impulsive behavior.

Many prevention programs have been initiated, such as suicide hotlines and crisis intervention centres, to ensure that suicidal numbers are reduced. The problem with this was that they sometimes had a counterproductive effect: more people committed suicide. The problem with these programs was that they wanted to make suicide a topic of discussion in the normal population, but at the same time they made suicide more acceptable to people with problems.

In the United States most suicides are committed with a pistol. People generally do not buy a gun to commit suicide, but use a gun they have had for some time. It could be that people who receive an impulse to commit suicide have too much the opportunity to possess weapons. If people did not have weapons, there would be a cooling-off period in which someone could think or go to a therapist.