PSYC 168: Ch 6 & 7 - Depressive, Bipolar Disorders, and Suicide

Depressive and Bipolar Disorders

• In DSM-5, depression and bipolar disorders are classified separately; DSM-IV calls them Mood Disorders.

Episodes

• Depressive, manic, and hypomanic episodes are the key episodic categories.

Disorders

• Major Depressive Disorder (unipolar depression)
• Persistent Depressive Disorder
• Bipolar I Disorder (mania, may w/ depression)
• Bipolar II Disorder (hypomania w/ depression)
• Cyclothymic Disorder

Unipolar Depression

• DSM-5-TR lists several types of depressive disorders, including:
  • Major depressive disorder
  • Persistent depressive disorder
  • Premenstrual dysphoric disorder
• 8% of U.S. adults experience severe unipolar depression in any given year, and 5% experience mild forms.
• 20% of adults experience unipolar depression in their lives.
• Women are twice as likely as men to have depression, with higher prevalence in transgender and nonbinary people.
• More prevalent in indigenous people and White people
• The average age of onset is 19 years old, with a peak in late adolescence and early adulthood.

Major Depressive Episode: Diagnostic Checklist

• For a 2-week period, individuals display either:
  • An increase in depressed mood for the majority of each day
  • A decrease in enjoyment or interest across most activities for the majority of each day.
• For the same 2 weeks, individuals also experience at least three or four of the following symptoms:
  • Considerable weight change or appetite change
  • Daily insomnia or hypersomnia
  • Daily agitation or decrease in motor activity
  • Daily fatigue or lethargy
  • Daily feelings of worthlessness or excessive guilt
  • Daily reduction in concentration or decisiveness
  • Repeated focus on death or suicide, a suicide plan, or a suicide attempt
• Significant distress or impairment

Major Depressive Disorder (MDD)

• This includes the presence of one or more major depressive episodes, but there is no history of mania or hypomania.
• Specific subtypes include:
  • Seasonal pattern (usually in winter)
  • Peripartum onset (related to pregnancy)
  • Melancholic features (loss of interest in everything)
  • Anxious distress

Persistent Depressive Disorder (Dysthymia): Diagnostic Checklist

• Depressed mood for most of the day for at least 2 years.
  • Note that children and adolescents may display an irritable mood, and the duration must be at least 1 year.
• The presence, while depressed, of two or more of the following:
  • Poor appetite or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration or difficulty making decisions
  • Feelings of hopelessness
• Over a 2-year period (1 year for children or adolescents), there can't be more than 2 months at a time without the symptoms.
• Absence of mania or hypomania history; a major depressive episode may occur at some time.
• Significant distress or impairment.

The Biological Model

• Genetic Factors: Supported by family pedigree, twin, and gene studies.

Biochemical Factors

• Key neurotransmitters: serotonin, norepinephrine, glutamate; lower levels are associated with depression.
• Hormones and HPA Pathway: stress can cause an over reactive Hypothalamic-pituitary-adrenal (HAP) axis
• Dysregulation of the Immune System: Stress leads to slower lymphocyte functioning, increased pro-inflammatory cytokine production, and greater inflammation.

Brain Circuits

• Main structures involved in circuits include the prefrontal cortex, hippocampus, amygdala, and subgenual cingulate.
• Irregular activity and flow rate occur in different brain locations.
• There is a smaller size of the hippocampus, and the subgenual cingulate is particularly small and active.
• Interconnectivity between brain parts is problematic.

Biological Treatments for Depression

• Antidepressant drugs are a common treatment.
• Monoamine oxidase (MAO) inhibitors
• Tricyclics
• Second-generation antidepressants
• Selective serotonin reuptake inhibitor (SSRI)
• Serotonin-norepinephrine reuptake inhibitor (SNRI)
• Ketamine-based drugs

MAO Inhibitors

• Accidentally discovered, these inhibit the MAO enzyme, thus increasing serotonin and norepinephrine levels.
• A special diet must be followed to avoid life-threatening side effects.
• They are not as common unless there is a specific reason to use them.

Tricyclics

• Accidentally discovered and featuring a three-ring molecular structure, these act on the neurotransmitter reuptake mechanism.
• People diagnosed with depression have a vigorous reuptake process; tricyclics inhibit this process to maintain neurotransmitter levels.
• Are still used, but as second-line treatments.

Second-Generation Antidepressants: Selective Serotonin Reuptake Inhibitors (SSRIs)

• Increase serotonin activity without affecting other neurotransmitters.
• Widely used with fewer side effects than traditional antidepressants.
• Common side effects include weight gain and reduced sexual drive.
• Examples include: Fluoxetine/Prozac, Sertraline/Zoloft & Escitalopram/Lexapro

Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)

• Increases both serotonin and norepinephrine activity.
• Venlafaxine/Effexor & Duloxetine/Cymbalta
• Other common medications include: Bupropion (Wellbutrin), Mirtazapine (Remeron), and Trazodone.

Ketamine-Based Antidepressants

• Ketamine was used as an anesthetic in the 1970s, but was later abused as a party drug.
• It increases activity of glutamate in the brain.
• Ketamine helps alleviate depression rapidly and can be combined with other drugs for those unresponsive to other treatments.
• Administered intravenously, the FDA recently approved a nasal spray, esketamine/Spravato.

Brain Stimulation

• Biological treatments directly or indirectly stimulate brain areas.

Methods for Brain Stimulation

• Electroconvulsive Therapy (ECT)
• Vagus Nerve Stimulation
• Transcranial Magnetic Stimulation (TMS)
• Deep Brain Stimulation

Electroconvulsive Therapy (ECT)

• Electrodes are attached to the head, and electricity is passed in 0.5 seconds.
• This induces a seizure for 15 to 70 seconds.
• Patients receive muscle relaxants or anesthetics to avoid injury and terror.
• ECT can cause memory loss.
• It shows improvement in 50% to 80% of patients.

Bipolar Disorders

• Characterized by lows of depression and highs of mania/hypomania.
• There are shifts between extreme moods, described as a roller coaster.
• Bipolar disorder has a dramatic impact on oneself, relatives, and friends.
• 1 to 2.8% of adults have bipolar disorder at any given time, and 4.4% have it at some point in life.
• Onset is typically between the ages of 15 and 44 years.
• There are no significant gender differences.
• Higher rates occur in low-income populations.

Manic Episode: Diagnostic Checklist

• For 1 week or more, the person displays a continually irregular, inflated, unrestrained, or irritable mood, coupled with heightened energy or activity, for most of every day (or any duration if hospitalization is necessary).
• Concurrent with the above, the individual experiences at least three the following symptoms. If the mood is only irritable, then four symptoms are necessary:
  • Grandiosity or overblown self-esteem
  • Reduced sleep need
  • Increased talkativeness, or drive to continue talking
  • Rapidly shifting ideas or the sense that one’s thoughts are moving very fast (flight of ideas)
  • The attention pulled in many directions (distractibility)
  • Heightened activity or agitated movements
  • Excessive pursuit of risky and potentially problematic activities
• The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

Hypomanic Episode: Diagnostic Checklist

• Lasting at least 4 consecutive days, a distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased activity or energy is present most of the day.
• During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted:
  • Inflated self-esteem or grandiosity
  • Decreased sleep need
  • More talkative than usual or pressure to keep talking
  • Flight of ideas, or subjective experience that thoughts are racing
  • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  • Increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation
  • Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
• The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
• The disturbance in mood and the change in functioning are observable by others.
• The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization; the presence of psychotic features constitutes a manic episode by definition.
• There are observable changes in functioning that are uncharacteristic

Mania versus Hypomania

• Mania and hypomania share many diagnostic criteria, but differ primarily in the duration of the episode and the effect on functionality.
• Mania causes considerable functional impairment, regularly necessitating hospitalization, while hypomania is not severe enough to cause functional impairment.
• Psychotic features may manifest in cases of mania, but not in hypomania.

Diagnosing Bipolar I Disorder

• Involves the occurrence of a manic episode.
• Hypomanic or major depressive episodes may precede or follow the manic episode, but are not required for diagnosis.

Diagnosing Bipolar II Disorder

• Involves the presence or history of major depressive episode(s).
• Also involves the presence or history of hypomanic episode(s).
• There is no history of a manic episode.
• Mania/hypomania and depression usually alternate, with depressive episodes being much longer.
• During the same period, having manic and depressive symptoms is called mixed features.
• Experiencing four or more manic, hypomanic, or depressive episodes within 12 months is considered rapid cycling.

Diagnostic Criteria for Cyclothymic Disorder

• Present with hypomanic and depressive symptoms for at least 2 years.
• Symptoms have been present for at least half the time, and the individual has not been without the symptoms for more than 2 months at a time.
• Criteria for a major depressive, manic, or hypomanic episode have never been met.
• Caused significant distress or impairment.
• Cyclothymic disorder may evolve into bipolar I or bipolar II.

Causes of Bipolar Disorders: Neurotransmitter Activity

• May be related to irregular activity of several neurotransmitters: norepinephrine, serotonin, glutamate, dopamine.
• Studies are conflicting and inconclusive

Ion Activity

• Information is transmitted by ions (Na+) within a neuron, leading to electrical firing.
• Improper transport of ions may cause neurons to fire too easily, resulting in mania, or resist firing, resulting in depression.

Brain Structure and Circuitry

• People with bipolar disorder have irregular brain structures, like a smaller hippocampus, basal ganglia, and cerebellum, smaller grey matters, and a depression-related circuit.
• It's unclear what roles the irregularities play.

Genetic Factors

• Many believe the key to bipolar may be a biological predisposition.
• Family pedigree studies, twin studies have confirmed this.
• Molecular biology techniques identify genes related to bipolar on 13 chromosomes.

Treatments for Bipolar Disorders

• Mood-stabilizing drugs

Lithium

• Dosage is carefully regulated and requires frequent monitoring to avoid toxicity, although used due to a limited alternative.
• Antiseizure drugs are safer and more tolerable than lithium.
  • Including Lamotrigine (Lamictal), Carbamazepine (Tegretol), and Divalproex/Valproate (Depakote).

Antipsychotic Drugs

• Help to stabilize mood.

Effect of Mood Medication

• Mania can usually be controlled well with a mood stabilizer.
• Bipolar depression is more challenging to treat sometimes.
• Antidepressants may trigger mania/hypomania in bipolar individuals.
• Psychiatrists should be skillful in managing medication.

Adjunctive Psychotherapy

• Psychotherapy alone is not helpful for Bipolar disorder.
• Patients need medication, so therapy can be supplemental or adjunctive.
• Therapy can increase medication adherence.
• Can help to reduce hospitalizations.
• It can improve social functioning and ability to obtain and hold a job.
• Therapy plays a more central role in cyclothymic disorder therapy because certain individuals may not take medication.

Cognitive-Behavioral Model for Depression

• Negative thinking can be a combination of maladaptive attitudes, cognitive triad, errors in thinking, and automatic thoughts.
• Depression results from maladaptive behaviors and dysfunctional thinking.
• Cognitive triad: Includes a negative views of experiences (world), oneself, and the future.

Beck’s Theory on Belief

• People suffering from depression have automatic thoughts, in addition to intermediate beliefs, as well as core beliefs
• Automatic thoughts are thoughts or images that pop up in our minds.
• Intermediate beliefs are rules and assumptions (if…then…).
• Core beliefs are fundamental opinions about the self, others, and the world.

Learned Helplessness

• Depression occurs when people believe they have no control over life’s reinforcements and assume responsibility for this helpless state.

Attribution-Helplessness Theory

• Internal attribution of a lack of control leads to feeling helpless, which will therefore prevent positive outcomes, in turn causing depression.

Cognitive-Behavioral Therapy for Depression: Behavioral Activation

• Reintroduction to pleasurable events/activities.
• Consistently reward nondepressive behaviors and withhold rewards for depressive ones.
• Help clients improve social skills.

Beck’s Cognitive Therapy

• Increases activities and elevates moods
• Challenges automatic thoughts
• Identifies negative thinking and biases
• Changes primary attitudes

Cognitive Reconstruction

• Analyzes dysfunctional thoughts while developing alternative thoughts, which is called cognitive reconstruction.
• Uses a thought record/log to document events/situations, thoughts/beliefs, and emotions/behavior.
• Many techniques: thoughts on trial, Socratic questions, cost-benefit analysis, behavioral experiment, decatastrophizing.

Sociocultural Model of Unipolar Depression

• Depression is influenced by social and cultural context.

Family-Social Perspective

• Depression ties into weak or unavailable social support, isolation, lack of intimacy, or an unhappy marriage.

Multicultural Perspective

• Depression is found worldwide, but symptoms vary.
• Non-Western countries are more likely to report physical symptoms than cognitive symptoms.
• Even though depression rates are higher in White populations, BIPOC populations have more recurrent episodes due to racism and other societal issues.

Suicide: Content Advisory and Resources

• The lecture involves the topic of suicide.
• Resources available:
• On campus Counseling center: at WELL, 916-278-6461, https://www.csus.edu/student-life/health-counseling/counseling/
• National Suicide Prevention Lifeline: call or text 988, or chat at 988lifeline.org
• Call 911 or go to the nearest emergency room.

Suicide Statistics and Factors

• Key points on suicide and related behaviors:

Suicide as a Leading Cause of Death

• It is one of the leading causes of death worldwide, with approximately 1 million deaths per year.
• 46,000 of those occur within the United States.
• Some 14 million have attempted suicide.
• In the U.S., 1.2 million demonstrate suicidal behavior called parasuicide.

Classification:

• Suicide is not classified as a mental disorder in DSM-5-TR but is considered a symptom or condition in disorders like Major Depressive Disorder and PTSD.
• A "Suicidal behavior disorder" has been proposed for the next revision.

Definitions: Suicide, Subintentional Death, and Non-Suicidal Self-Injury (NSSI).

• Suicide: Self-inflicted death by way of intentional and conscious means.
• Subintentional death: Indirect/covert. Examples of this can be found in drug and alcohol abuse, as well as medication mismanagement.
• Nonsuicidal self-injury (NSSI): Includes deliberate destruction of one's body without the intention to die, with about 20% of adolescents reported to injure themselves.

Key Patterns and Statistics for Suicide Include:

• Varying rates across countries, genders, sexual orientation and gender identity, race and ethnicity, marital and relationship status, and religious devoutness.

Common Triggers for Suicide

• Stressful events such as isolation, serious illness/injury, and abusive environments.
• Includes mood and thought changes involving hopelessness.
• Concurrent with alcohol and other drug use.
• It is connected to mental disorders, most notably depression (70%), chronic alcoholism (20%), and schizophrenia (10%).
• It can be modeled by family, friends, and celebrities.

Is Suicide Linked to Age?

• Suicide is uncommon among children but starts to rise among adolescents (more attempts in teens).
• It's relatively stable in adults.
• Suicide gradually declines from midlife, then rises again in older adults.

Treatment of Suicide

• Treatments include medical care and follow-up with psychotherapy and medication.
• The point of therapy is to keep the patient alive.
• Other goals include reducing psychological pain and achieving a nonsuicidal state of mind.
• Goals also include building a sense of hope, restricting dangerous means, and developing better stress management.
• Key approaches: CBT and Dialectical Behavior Therapy (DBT).

Prevention

• There are also key steps for suicide prevention and crisis intervention, including hotlines and professionals.
• Examples of hotlines and crisis intervention include professional or paraprofessional staff, the use of Crisis Text Line and online chat, and Trevor Project for LGBTQ+ teens)

988 Suicide & Crisis Lifeline

• A national suicide prevention service, reachable at the 988 number.
• It routes persons in crisis to a nearby crisis center (more than 200 in the U.S.).
• There the individuals receive immediate counseling and mental health resources and referrals.

Key Suicide Prevention Goals

• Establishing a positive relationship
• Understanding and clarifying the problem
• Assessing suicide potential.
• Assessing and mobilizing the caller's resources
• Formulating a plan (safety planning)
• Includes referral for longer-term therapy and safety planning.
• It reduces access to dangerous means.
• Public education is key and promotes successful wide scale suicide treatment among adolescents.

Safety Planning:

• Involves identifying warning signs, internal coping skills, identifying distraction resources, knowing people who can provide help, developing professional and emergency resource contacts, and making the environment safe.