Class 3: Mood Disorders and Suicide (Chapter 8) PDF

Class 3: Mood Disorders and Suicide (Chapter 8) Introduction to Psychopathology Instructor: Dr. Dean Carcone, C.Psych 1  Got the blues?  Are we pathologizing sadness?  Almost everyone experiences transient periods of feeling down...

Class 3: Mood Disorders and Suicide (Chapter 8) Introduction to Psychopathology Instructor: Dr. Dean Carcone, C.Psych 1  Got the blues?  Are we pathologizing sadness?  Almost everyone experiences transient periods of feeling down and depressed as well as feeling high and getting joy out of life. Remember emotions have functions. Sadness can communicate a need to others, such that we are hurt, lonely, or need help, signal to us that something needs to change, or help us conserve energy.  Got the blues?  The spectrum of mood is important to consider from very mild and transient to severe and persistent  Major Depressive Disorder  Prevalence at 5%-12.5%  50% of those who have one episode will have another  ~90% of those who have two or three will have more  Average episode lasts 6-9 months but can be shorter or longer  Average age of first onset is early to mid-20s but the onset age is decreasing (e.g., teens)  Women are also higher risk of developing the disorder at all ages  Comorbid with anxiety disorders (upwards of 50%) which contributes to more severe and chronic course of depression  Major Depressive Disorder (DSM-5 criteria) A. Five or more of the following symptoms, at least one is depressed mood or anhedonia. (1) Depressed Mood = Subjective report (feels (2) Anhedonia = Markedly diminished interest sad, empty, hopeless) or observation made by or pleasure in all, or almost all, activities others (appears tearful). (subjective or observation). (3) Significant weight loss when not dieting or weight gain (+5% in a month), or decrease in appetite nearly every day. (4) Insomnia or hypersomnia (usually +/- 2 hour change). (5) Psychomotor agitation or retardation nearly every day (observable, not merely B = Distress or subjective feelings of restlessness or being slowed down). impairment. C = Not due to (6) Fatigue or loss of energy nearly every day. substance/med. (7) Feelings of worthlessness or excessive/inappropriate guilt (which may be D = No psychotic delusional and not merely self-reproach about being sick). disorder. (8) Difficulty concentrating, or indecisiveness. E = never had manic/hypomanic (9) Recurrent thoughts of death, suicidal ideation without a plan, or a suicide Episode. attempt or a specific plan for committing suicide. Remember: Each criterion is assessed on the frequency of most of the day, nearly every day for at least a two week period (commonly > one month). https://www.youtube.com/watch?v=7LD8iC4NqXM&t=11s  Major Depressive Disorder  Removal of the bereavement exclusion from the DSM-5, could lead to increased prevalence.  The number of criteria to make a diagnosis is contentious (why 5 not 4?).  Between actual episodes, some people have no symptoms (full interepisode recovery) whereas some people have several lingering symptoms (without full interepisode recovery).  Major Depressive Disorder  Some of the world’s most famous people have and still deal with depression. Jim Carrey suffers from depression and has taken Prozac to combat the symptoms. He has stated that he no longer takes medications or stimulants of any kind, including coffee. Dwayne (“The Rock”) Johnson: "I reached a point where I didn't want to do a thing or go anywhere," he said. "I was crying constantly.“. Shortly after being cut from the CFL's Calgary Stampeders, Johnson says his girlfriend broke up with him, leading to his "absolute worst time" dealing with mental health issues Andrew Solomon’s vivid description of the disorder and the issues in treatment: https://www.ted.com/talks/andrew_solomon_depression_the_secret_we_share?language=en  Major Depressive Disorder  Some of the world’s most famous people have/deal with depression. Many comedians valued the way Hugh Laurie first concluded he had Robin Williams worked highly a problem whilst driving in a personal issues into his comedy charity demolition derby, during routines, especially his honesty which he realized that seeing two about drug and alcohol cars collide and explode in front of addiction, along with him caused him to be neither depression. According to media excited nor frightened, but bored. scholar Derek A. Burrill, because He continues to have regular of the openness with which sessions with his psychotherapist. Williams spoke about his own "Boredom," he commented, "is not life, "probably the most an appropriate response to important contribution he made exploding cars." to pop culture, across so many different media, was as Robin Williams the person."  Persistent Depressive Disorder  Previously called “dysthymia” until DSM-5, prevalence 3%  Chronic low mood that lasts for at least two years, along with at least three associated symptoms  Many experience both this chronic low mood and additional episodes of depression on top of this, called double depression  First two are considered “double depression” https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20200325124118 262-0720:S0924933800066323:S0924933800066323_fig1.png?pub-status=live  Persistent Depressive Disorder  Tends to be more chronic, younger age of onset, higher comorbidity, strong family history, lower levels of social support, higher stress and dysfunctional personality traits  Also less likely to respond to standard treatment protocols  Often needs a combination treatment, not just one  One theoretical concern that continues is: just how differentiated is this from a normal-range personality traits (e.g., high N, low E)  Persistent Depressive Disorder (DSM-5 criteria) (A) Depressed Mood: Most of the day, for more days than not (subjective account or observable to others) for at least 2 years. (B) Presence, while depressed, of two or more of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness (C) During the 2-year period (1 year for children/adolescents), person has never been without symptoms in A or B for more than 2 months at a time. (D) Criteria for MDD may be continuously present for 2 years (NEW). (E) There has never been a manic or hypomanic episode, and never met criteria for cyclothymia. (F/G) Not better explained by other mood disorders or substance/medication. (H) Symptoms cause clinically significant distress/impairment.  Other depressive disorders  Premenstrual Dysphoric Disorder (1.8-5.8%)  Acute depressive symptoms that accompany the menstrual cycle in women  Must occur in most of the menstrual cycles in the past year  Research focuses on hormonal mechanisms (birth control/SSRIs can help)  Other Specified Depressive Disorder  Recurrent brief depression (5+ symptoms, 2-13 days, each month for at least one year)  Short-duration depressive episode (4-13 days, 5+ symptoms)  Depressive episode with insufficient symptoms (at least two weeks)  Unspecified Depressive Disorder  Adjustment Disorder – we will discuss more in a later lecture  With depressed mood (“emotional or behavioral” symptoms for 3 months but do not meet full criteria for MDE)  Bipolar Disorders  Mania = a distinct period of elevated, expansive, or irritable mood that lasts for at least one week (7+ days)*, associated with:  Increased energy, decreased need for sleep, racing thoughts, pressured speech, impaired attention/concentration/judgment  Can lead to altercations with others, reckless activities (gambling, sexual indiscretions), substance use, and aggression *Any duration would count if hospitalization is necessary or if there is interaction with law enforcement.  Hypomania = less severe than above, but only lasting at least 4 days  Can be longer if it did not cause significant difficulties to warrant a mania episode  Given lesser severity, can sometimes be hard to distinguish between “feeling good”  Rarer, but sometimes depression and manic/hypomanic symptoms can be felt at the same time = mixed-state episodes Bipolar I Disorder (DSM-5 criteria for a Manic Episode) (A) Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization/law). (B) During period of mood disturbance and increased energy/activity, 3+ of the following symptoms (FOUR if only irritable) are present to a significant degree and are a noticeable change from usual: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., rested after 3 hours) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or feeling of facing thoughts 5. Distractibility (attention easily unfocused) 6. Increase in goal-directed activity (social, work, school, sexual) or psychomotor agitation (purposeless non-goal-directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences (spending sprees, sexual indiscretions, gambling) (C): Impairment (no mention of “distress”) in functioning or need of hospitalization to prevent harm to self or others, or there are psychotic features. (D) Not attributable to substance/medical condition.  Bipolar I Disorder  Bipolar I disorder is diagnosed when at least one manic episode is present (not exclusively during an episode of psychosis), irrespective of their history of depression  However, most patients have had MDD in the past (or will have new MDD)  Prevalence, 0.8%; equal M/F  Mean onset ~20 y.o., 50% show symptoms as teens https://www.youtube.com/watch?v=tJeEVVYV8xE For interest, see https://www.youtube.com/watch?v=mpE-oaix5kA for a longer interview with a client. Bipolar II Disorder (DSM-5 criteria for a Hypomanic Episode) (A) Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. (B) [Same symptoms as Bipolar I disorder] (C) The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. (D) The disturbance in mood and change in functioning is observable to others. (E) Not severe enough to cause marked impairment in functioning (social, occupational) or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. (F) The episode is not attributable to a substance or medication.  Bipolar II Disorder  Bipolar II disorder is diagnosed when at least one episode of hypomania is present and one or more depressive episodes (not exclusively during episodes of psychosis)  Prevalence: 0.5%; equal M/F  “"Hypomanic people by definition are not causing major damage in their life. In fact, they usually feel terrific. They're more productive than usual, they sleep a little less, they have more energy. They and lots of people around them would say, 'Gee, they're doing great. There's nothing wrong with them.' It's only later in retrospect that we realize that they actually have https://www.youtube.com/watch?v=vcCBacPWLrc hypomanias.“ - Michael Gitlin, professor of https://www.vice.com/en/article/yp98bm/i- clinical psychiatry at the UCLA School of thought-i-was-depressed-but-it-turns-out-im-bipolar Medicine  Bipolar Disorders  Manic symptoms are often experienced as enjoyable and pleasurable at first  E.g., more productive, interest in things, ideas are sharp, able to accomplish more  But they tend to progress into something more distressing and impairing  Other people may become frightened and worried  Reckless activities can attract financial problems, drug use, law enforcement, interpersonal problems  Sepressive episodes tend to be more severe as the change in symptoms is very prominent  Hypomanic/manic episodes tend to last two weeks to four months  Depressive episodes tend to last between 6 to 9 months  Rates of suicide are between 10-15%  Other Cyclical Mood States  Cyclothymia = chronic, but less severe form of bipolar disorder  Hypomanic and depressive symptoms, but never reach full DSM criteria for either  Still at risk for developing bipolar disorders  Rare diagnosis, 0.4-1% prevalence and equal across gender  Very difficult to get a diagnosis – are symptoms just normal fluctuation or cyclothymia?  Rapid-cycling specifier = four or more manic and/or depressive episodes within 1 year; episodes must be separated from each other by at least 2 months of full or partial remission or by a switch to the opposite mood state Seasonal Affective Disorder (SAD)  SAD represents recurrent depressive episodes that are tied to changing seasons, usually winter months with less daylight  Approximately 11% of those with MDD have SAD  General prevalence is 0.9-3% (Canada = 2-3%)  Etiology focused on melatonin, a hormone produced at night by the pineal gland  But medications that suppress melatonin are not very effective.  Phototherapy helps the body enter the awake phase more effectively  Peri-Partum and Post-Partum Onset Depression  10-15% of mothers have mood swings that do not resolve or are severe enough to meet criteria for MDD or Manic episode  0.1% have post-partum psychosis, which may lead to mother committing suicide (5% of cases) or infanticide (4% of cases)  Risk factors: family history of depression, previous personal depression, poor marital relationship, low social support, stressful life events concurrent/following childbirth  Could have adverse impact on the child (e.g., attachment formation, other vulnerabilities)  Quiz Naomi is a 21-year-old woman who has been experiencing mood swings for the past two years. For most of this time, she has felt low, sometimes so low she has felt hopeless and contemplated suicide. These depressive episodes typically last for a few weeks, during which she feels extremely sad, has trouble sleeping, and struggles to find motivation to do anything. At times, she has also felt the opposite: so good that she has gotten into significant trouble. These episodes involve periods of heightened energy, racing thoughts, impulsivity, and decreased need for sleep. In the last year, she has felt low at almost all times except three periods when she was depressed, and two periods lasting eight days when she was manic, with extremes alternating between each other. Naomi's mood shifts can be severe and disruptive to her daily life. A) bipolar I disorder B) rapid cycling bipolar disorder C) major depressive disorder D) bipolar II disorder E) cyclothymia F) persistent depressive disorder https://strawpoll.com/X3nkPmD9jgE 27  Break Time  Play with ChatGPT: https://chat.openai.com  Practice generating vignettes for your assignment?  Ask it to quiz you on mood disorders?  Ask it to make a mnemonic to remember the symptoms of MDD?  Etiology of Mood Disorders No matter the theory, almost all are diathesis-stress models, because it appears Environment Stressors Biological that many vulnerabilities (stressful life (genetics, events, exist but stressful events traits) relationships, are still needed to pass family) depressive threshold. Psychological Factors (personality, cognitive style)  Biological Causal Factors Genetics Caspi et al., 2003  Twin studies show:  A high heritability of developing MDD: 36%  A HUGE heritability of developing BP: 75%  Role of serotonin transporter gene (HTT)  Long vs short allele  Individuals’ reactivity to stress  Higher rates of MDD in response to stress for individuals with s/s and s/l  ‘s’ allele is associated with negative cognitive style and personality 30  Psychological Factors  Personality styles:  Dependency: relying on interpersonal relationships for sense of identity; neediness, fearing abandonment, and feeling helpless in relationships  Self-criticism: particularly towards achievement; fears of failure, self- blame, inferiority, guilt  Behavioral models:  Lewinsohn’s behavioral model: based on operant conditioning, low rate of positive reinforcement via social and other rewards (environment no longer provides reinforcement, thus extinction of those behaviors)  Seligman’s learned helplessness model: remain in unpleasant situations when they start to believe they have no control, even when options to escape/control exist  Cognitive Theories  Ellis: irrational and distorted thoughts  Beck: negative bias in appraising stimuli from the environment facilitates negative mood  Formed basis for cognitive distortions framework  Cognitive distortions are apparent in our automatic thoughts because of underlying schemata about the self, world, and the future An example of Appraisal Theory  Cognitive Theories  Cognitive Distortions  Beck’s cognitive model  Diathesis-stress model  E.g., only after a breakup might someone’s core schema around being unlovable start to cause difficulties 33  Attentional/Interpersonal Theories  Attentional bias:  Depressed people preferentially attend to negative info in their environment  Not as animated, more negative affect, angry/depressed feelings  More likely to be judged as less socially-skilled  People in mania may preferentially attention to positive stimuli (reward/incentive) in their environment  Seeking out negative feedback  Depressed people tend to actively seek confirmation of criticism and other negative interpersonal beliefs from others, can provoke further negative responses  Interpersonal dependency, or excessive reassurance seeking  Tendency to seek assurance about one’s worth and lovability from others, regardless of whether such assurances have already been provided  Life Stress Perspective  Depressed people are 3x as likely to experience a stressful life event prior to onset  Themes of loss vs. reward  Especially sudden losses or sudden changes  Nearly 75% with MDD have suffered major loss event 3-6 months before  Life events related to reward/goal attainment predict increases in manic symptoms  Early child maltreatment  Leads to internalization of negative core schemas “I’m unlovable” “people are out to hurt me” “the world is a dangerous place”  Often taxes the biological systems (e.g. HPA axis, cortisol levels, etc.)  Biological Theories In general, Bipolar Disorder has a higher genetic basis than Major Depressive Disorder Broad Genetics (Heritability) Twin Studies Family Studies (MZ vs. DZ) MDD vs. BP 5HTT HPA axis polymorphisms (over-activated) “s/s” or “s/l” at greater risk Neurotransmitters (5HT, NE, DA)  -This is a DEBUNKED theory of MDD Neurotransmitters See https://www.nature.com/articles/s41380-022-01661-0 for debunking Normal Stress Response (HPA Axis) Hippocampus Amygdala Effect of Chronic Stress Hypothalamus Pituitary Glands Cortisol Adrenal Glands Cortisol Cascade Hypothesis Summary Cortisol release during stress stimulates receptors in the hippocampus. The hippocampus inhibit the HPA axis by negative feedback. Chronic stressors result in sustained release of cortisol and a breakdown of the negative feedback inhibition of the HPA axis. Prolonged periods of cortisol hypersecretion have been found to kill brain cells and cause permanent damage to the hippocampus. Supporting studies: The HPA axis is more reactive in females (2x depression) The greater lifetime stress experienced, the smaller a person’s hippocampi (Carcone, 2022 ☺) Child abuse is associated with death of cells in the hippocampus and amygdala (regulation of mood and emotional memory) 39  Sleep Neurophysiology MDD: loss of slow-wave sleep and earlier onset of first REM stages (characterized by higher frequency and amplitude of eye movements) Sleep deprivation can induce symptoms of mania and people have suggested that BP is related to sleep dysregulation  Neuroimaging  Depression is associated with decreased blood flow and reduced glucose metabolism in prefrontal cortex (in some regions, reversed in mania)  Also increased glucose metabolism in subgenual ACC, seems to be related to attentional biases  Also increased activity in the amygdala.  (among many other differences)  CBT for Depression  Goals: increase awareness of thoughts and appraisals to events, and to examine how these cognitions contribute to the emotional reactions that follow  Structured format, 16-20 sessions  Socratic questioning and guided discovery  Activity Monitoring and Scheduling  “Behavioural activation”  To counteract Lewinsohn’s theory  Challenging distorted thinking: thought records  Behavioral Experiments  Some evidence that CBT is superior to psycho- dynamic psychotherapy, but comparable results to antidepressants and IPT  But lower relapse rates in the long-term with CBT  Behavioral activation appears to be a critical component  Mindfulness-Based Cognitive Therapy for MDD  Mindfulness-Based Cognitive Therapy (MBCT)  Using Buddhism principles to promote a non-evaluative awareness of the present  Detach from ruminative thinking and cultivate a decentered, detached perspective to depression-related thoughts and feelings  Only 40% of those receiving MBCT after treatment for depression relapsed whereas 66% in TAU group (check in with family doctor) relapsed Some techniques https://www.youtube.com/wat ch?v=8oWmGJc8NWI https://www.youtube.com/wat ch?v=r1C8hwj5LXw&t=26s https://www.youtube.com/wat ch?v=1A4w3W94ygA  Interpersonal Psychotherapy (IPT)  Based on psychodynamic theories viewing loss and disordered attachment as underlying factors  Assumes depression occurs via an interpersonal context (e.g., work-related)  Typically 12-16 sessions, working to resolve interpersonal conflicts in the following areas:  Interpersonal disputes: marital, family, other relationships  Role Transitions: life changes  Grief: loss/mourning  Interpersonal deficits: skills to improve/ add new relationships  Treatment efficacy was similar to antidepressants and maintenance sessions work to prevent relapse  Pharmacotherapy for Depression  TCAs: blocks reuptake of NE and/or 5HT  MAOIs: block the MAO enzyme, which prevents breakdown of NE, 5HT, DA  SSRIs: primarily target 5HT, blocking reuptake  Common side effects: nausea, insomnia, sedation, and sexual dysfunction  SNRIs: block reuptake for 5HT and NE  E.g., (des)venlafaxine (Effexor), Remeron (mirtazapine)  Medications that work on dopamine  E.g., modafinil and pramipexole (stimulant-like)  Other miscellaneous actions (e.g., gabapentin working on GABA)  Another newer medication is ketamine for severe depression (similar effect sizes to ECT)  Exact mechanisms of action are not understood, but we have an idea of which systems are involved.  Antidepressants: ~50 of people who finish a trial of medication do respond  Pharmacotherapy for Bipolar Disorder  Lithium: a mood stabilizer used for many years (since 1949 clinically)  Mechanism of action: ¯\_(ツ)_/¯  Might deactivate GSK-3B protein, which is related to the circadian clock; when the GSK-3B enzyme is active, proteins are unable to reset the body’s master clock  May also work on decreasing glutamate (excitatory) more broadly  Downside: narrow therapeutic window means that you may have to get blood draws regularly, because the therapeutic dose is slightly below the toxic dose  Can also effect kidneys & thyroid; dehydration, weight gain; thinning of hair, hand tremor  Have to be careful with coffee and salt intake  Pharmacotherapy for Bipolar Disorder  About 40% do not respond to Lithium  May become ineffective over time for about 70%  Anticonvulsants are second choice, originally used for epilepsy but also has mood stabilizing effects  Examples: Carbamazepine, valproate, lamotrigine, gabapentin, topiramate, oxcarbazepine, etc.  Unfortunately, we don’t exactly know how these work to stabilize mood either:  Many work by increasing the release and synthesis of GABA while others work by decreasing glutamate Likely  Some work on Calcium channels or Sodium channels, Not which help to regulate action potentials Tested  Pharmacotherapy for Bipolar Disorder  Atypical antipsychotics are generally newer drugs that also offer a mood-stabilizing effect  Good for psychotic symptoms which can emerge  Works on dopamine and serotonin systems  Examples: Aripiprazole, clozapine, ziprasidone, risperidone, quetiapine, and olanzapine  Some side effects: can sometimes cause tardive dyskinesia  Antidepressants less prescribed for BP because they can promote a manic episode!  Except: Wellbutrin because it works on NE/DA, not 5HT  Combination Therapies for Bipolar Disorder  For bipolar disorder, 1st choice is medication but can add adjunct therapy:  Family-focused therapy (FFT): education for the patient and family; communication and problem-solving training; developing positive ways of interacting that keep their relationships supportive over the long term  Interpersonal and Social Rhythm Therapy (IPSRT): regulation of routines and coping with stressful live events; targets sleep-wake cycle and consistency, which helps to prevent relapse (via sleep deprivation)  Cognitive Therapy (CT): regulate sleep and daily routines; monitor mood for triggers for manic/depressive episodes; medication compliance  Dialectical Behavioural Therapy (DBT): Improve emotional regulation, reduced negative coping behaviors, reduced vulnerability to strong emotions  Phototherapy  Light boxes emit a bright light that mimics sunlight  Has to be certain intensity (~10,000 lux)  Patients are asked to sit in front of the box for 30 minutes in the morning  This effect will mimic the physiological processes that sunlight has on the body (e.g., increasing temperature, serotonin production, melatonin inhibition)  First line treatment for SAD and costs