Mood Disorders And Suicide PDF

AS2402 MOOD DISORDERS AND SUICIDE Depression and Mania The disorders to be discussed in this module used to be categorized under several general labels, such as “depressive disorders,” “affective disorders,” or even “depressive neuroses.” Beginning with the third e...

AS2402 MOOD DISORDERS AND SUICIDE Depression and Mania The disorders to be discussed in this module used to be categorized under several general labels, such as “depressive disorders,” “affective disorders,” or even “depressive neuroses.” Beginning with the third edition of the Diagnostic and Statistical Manual (DSM-III), these problems have been grouped under the heading mood disorders because gross deviations in mood characterize them. The fundamental experiences of depression and mania contribute, either singly or together, to all mood disorders. The most commonly diagnosed and most severe depression is called a major depressive episode. The DSM-5 criteria describe it as an extremely depressed mood state that lasts at least two (2) weeks and includes cognitive symptoms and disturbed physical functions to the point that even the slightest activity or movement requires an overwhelming effort. Evidence suggests that the most central indicators of a full major depressive episode are the physical changes (sometimes called somatic or vegetative symptoms) (Regier et al., 2013; Tang & Thomas, 2020), along with the behavioral and emotional “shutdown,” as reflected by low behavioral activation (Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011). Individuals with depression often exhibit dysfunctional reward processing and anhedonia, which is characterized by a loss of energy and an inability to derive pleasure from activities. The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or euphoria. In mania, individuals find extreme pleasure in every activity. They become extraordinarily active (hyperactive), require little sleep, and may develop grandiose plans, believing they can accomplish anything they desire. Speech is typically rapid and may become incoherent because the individual attempts to express so many exciting ideas simultaneously; this feature is generally referred to as a flight of ideas. DSM-5 criteria for a manic episode require only one (1) week, less if the episode is severe enough to require hospitalization. Hospitalization could occur, for example, if the individual were engaging in a self-destructive buying spree, charging thousands of dollars in the expectation of making a million dollars the next day. Irritability is often part of a manic episode, usually near the end. DSM-5 also defines a hypomanic episode as a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning and needs to last only four (4) days rather than a full week. (Hypo means “below”; thus, the episode is below the level of a manic episode.) A hypomanic episode is not in itself necessarily problematic, but its presence does contribute to the definition of several mood disorders. Individuals experiencing either depression or mania are classified as having a unipolar mood disorder, as their mood remains fixed at one end of the depression–mania spectrum. While unipolar mania exists, it is rare, with most individuals with a unipolar mood disorder eventually developing depression. Alternating between depression and mania characterizes bipolar mood disorder, where mood shifts between the extremes of depression and elation. However, the term "bipolar" can be somewhat misleading as depression and joy may not be at exactly opposite ends of the same mood state; although related, they are often relatively independent. 05 Handout *Property of STI  [email protected] Page 1 of 9  AS2402 An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time or be depressed with a few symptoms of mania. This episode has “mixed features” (Baldessarini, Vazques, & Tondo, 2020; Na, Kang, & Cho, 2021). It is important to determine the course or temporal patterning of the depressive or manic episodes. Do the depressive episodes alternate with manic or hypomanic episodes or not? All these patterns for mood disorders are important to note since they contribute to decisions on which diagnosis is appropriate. Full remission – If the depressive or manic episodes tend to recur, the patient fully recovers for a least two (2) months between episodes. Partial remission – The patient only partially recovers, retaining some depressive symptoms. Criteria for Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: It can be irritable in children and adolescents.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly daily. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note: Criteria A–C constitutes a major depressive episode. Note: Responses to a significant loss (e.g., grief, financial ruin, losses from a natural disaster, a serious medical illness, or disability) may include feelings of intense sadness, rumination about the loss, 05 Handout *Property of STI  [email protected] Page 2 of 9  AS2402 insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode, in addition to the normal response to a significant loss, should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for expressing distress in the context of loss. Criteria for Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one (1) week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., rested after only 3 hours). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities with a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. 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. D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. Note: Criteria A–D constitute a manic episode. Depressive Disorders Major Depressive Disorder The several types of depressive disorders differ from one another in the frequency and severity with which depressive symptoms occur and the course of the symptoms (chronic—meaning almost continuous—or nonchronic). Major depressive disorder is defined by the presence of depression and the absence of manic or hypomanic episodes before or during the disorder. If two or more major depressive episodes occurred and were 05 Handout *Property of STI  [email protected] Page 3 of 9  AS2402 separated by at least two (2) months during which the individual was not depressed, the major depressive disorder is noted as being recurrent. Persistent depressive disorder (dysthymia) shares many of the symptoms of major depressive disorder but differs in its course. There may be fewer symptoms, but depression remains relatively unchanged over long periods, sometimes 20 or 30 years or more (Angst, 2009; Cristancho, Kocsis, & Thase, 2012; Klein, 2008; Klein, Shankman, & Rose, 2006; Murphy & Byrne, 2012). Persistent depressive disorder is defined as a depressed mood that continues for at least two (2) years, during which the patient cannot be symptom-free for more than two (2) months at a time, even though they may not experience all of the symptoms of a major depressive episode. It is considered more severe since patients with persistent depression present with higher rates of comorbidity with other mental disorders, are less responsive to treatment, and show a slower rate of improvement over time. Individuals who have major depressive episodes and persistent depression with fewer symptoms are said to have double depression. Typically, a few depressive symptoms develop first, perhaps at an early age. Then, one (1) or more major depressive episodes occur later, only to revert to the underlying pattern of depression once the major depressive episode has run its course (Boland & Keller, 2009; Klein et al., 2006). DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER A. At least one major depressive episode (See criteria A-C from Major Depressive Episode) B. At least one major depressive episode is not better explained by schizoaffective disorder. It is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. C. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance- induced or are attributable to the physiological effects of another medical condition. Specify if: A single episode or recurrent episode Mild, moderate, severe With psychotic features With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern (recurrent episode only) In partial remission, in full remission Specifiers may or may not accompany a depressive disorder, but when they do, they are often helpful in determining the most effective treatment or likely course. Some of these specifiers apply only to major depressive disorder. Others apply to both major depressive disorder and persistent depressive disorder. 05 Handout *Property of STI  [email protected] Page 4 of 9  AS2402 1. Psychotic features specifier: Hallucinations and delusions during major depressive or manic episodes. 2. Anxious distress specifier: Presence and severity of accompanying anxiety symptoms. 3. Mixed features specifier: Major depressive episodes with symptoms of mania. 4. Melancholic features specifier: Severe somatic symptoms in major depressive episodes. 5. Catatonic features specifier: Involves an absence of movement (a stuporous state) or catalepsy, in which the muscles are waxy and semirigid, so a patient’s arms or legs remain in any position they are placed. 6. Atypical features specifier: Oversleeping, overeating, and potential comorbid disorders in depression. 7. Peripartum onset specifier: Major depressive or manic episodes surrounding childbirth. 8. Seasonal pattern specifier: Recurrent episodes corresponding to certain seasons, such as winter depression. (Seasonal affective disorder) DIAGNOSTIC CRITERIA FOR PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least two (2) years. Note: In children and adolescents, mood can be irritable, and duration must be at least one (1) year. 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 or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than two (2) months at a time. D. Criteria for a major depressive disorder may be continuously present for two (2) years. E. There has never been a manic episode or a hypomanic episode. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: If criteria are sufficient for a diagnosis of a major depressive episode at any time during the two (2) years of depressed mood, then a separate diagnosis of major depression should be made in addition to the diagnosis of persistent depressive disorder along with the relevant specifier (e.g., with intermittent major depressive episodes, with current episode). 05 Handout *Property of STI  [email protected] Page 5 of 9  AS2402 Specify if: With anxious distress With atypical features Specify if: In partial remission In full remission Specify if: Early onset: If onset is before age 21 years Late onset: If onset is at age 21 years or older Specify if (for most recent two (2) years of persistent depressive disorder): With pure dysthymic syndrome With persistent major depressive episode With intermittent major depressive episodes, with current episode With intermittent major depressive episodes, without current episode Specify current severity: Mild Moderate Severe A new diagnosis of prolonged grief disorder, where individuals experience intense grief that lasts a year or more, is found in many new pieces of literature concerning this topic. However, the natural grieving process called acute grief can also be closely related to depression. Other depressive disorders include Premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder. The essential features of premenstrual dysphoric disorder are the expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly after that. Behavioral and physical symptoms may accompany these symptoms. Symptoms must have occurred in most of the menstrual cycles during the past year and must have an adverse effect on work or social functioning. The intensity and/or expressivity of the accompanying symptoms may be closely related to social and cultural background characteristics, religious beliefs, social tolerance, attitude toward the female reproductive cycle, and gender role issues. The core feature of disruptive mood dysregulation disorder is chronic, severe, persistent irritability. This severe irritability has two prominent clinical manifestations, the first of which is frequent temper outbursts. These outbursts typically occur in response to frustration and can be verbal or behavioral (the latter in aggression against property, self, or others). They must occur frequently (i.e., on average, three or more times per week) over at least one (1) year in at least two settings, such as in the home and at school, and they must be developmentally inappropriate. The second manifestation of severe irritability consists of a chronic, persistently irritable, or angry mood that is present between severe temper outbursts. This irritable or angry mood must be characteristic of the child, being present most of the day, nearly every day, and noticeable by others in the child’s environment. 05 Handout *Property of STI  [email protected] Page 6 of 9  AS2402 Bipolar Disorders The original term for this group of disorders was manic-depressive illness, which was first introduced by Emil Kraepelin (Kendler, 2021). The key identifying feature of bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes in an unending roller-coaster ride from the peaks of elation to the depths of despair (McIntyre et al., 2020). Beyond that, bipolar disorders are parallel in many ways to depressive disorders. In bipolar I disorder, major depressive episodes alternate with full manic episodes. The criteria for bipolar II disorder are the same, except the individual experiences hypomanic episodes rather than full manic episodes. As in the criteria set for major depressive disorder, for the manic episodes to be considered separate, there must be a symptom-free period of at least two (2) months between them. Otherwise, one episode is seen as a continuation of the last. A milder but more chronic version of bipolar disorder is called cyclothymic disorder (Akiskal, 2009; Parker, McCraw, & Fletcher, 2012). Cyclothymic disorder is a chronic alternation of mood elevation and depression that does not reach the severity of manic or major depressive episodes. Individuals with cyclothymic disorder tend to be in one mood state or the other for years with relatively few periods of neutral (or euthymic) mood. This pattern must last for at least two (2) years (one year for children and adolescents) to meet the criteria for the disorder. For depressive disorders, we discussed additional defining criteria that may or may not accompany a mood disorder. All of these same specifiers apply to bipolar disorders. Still, one specifier that is unique to bipolar I and II disorders is the rapid-cycling specifier, where individuals experience at least four manic or depressive episodes within a year. In most cases, rapid cycling tends to increase in frequency over time and can reach severe states in which patients cycle between mania and depression without any break. When this direct transition from one mood state to another happens, it is referred to as rapid switching or rapid mood switching and is a particularly treatment-resistant form of the disorder (MacKinnon, Zandi, Gershon, Nurnberger, & DePaulo, 2003; Maj, Pirozzi, Magliano, & Bartoli, 2002). Some cases exhibit ultra-rapid cycling lasting days to weeks or even ultra-ultra-rapid cycling with cycle lengths less than 24 hours. DIAGNOSTIC CRITERIA FOR BIPOLAR I DISORDER For a diagnosis of bipolar I disorder, it is necessary to meet the criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. Criteria have been met for at least one manic episode. At least one manic episode is not better explained by schizoaffective disorder. It is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders. Note: At least one-lifetime manic episode is required for the diagnosis of bipolar I disorder. Note: Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note: Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. 05 Handout *Property of STI  [email protected] Page 7 of 9  AS2402 *Indicate specifiers if applicable DIAGNOSTIC CRITERIA FOR BIPOLAR II DISORDER A. Criteria have been met for at least one hypomanic episode and at least one major depressive episode. Criteria for a hypomanic episode are identical to those for a manic episode, with the following distinctions: (1) Minimum duration is four days; (2) although the episode represents a definite change in functioning, it is not severe enough to cause marked social or occupational impairment or hospitalization; (3) there are no psychotic features. B. There has never been a manic episode. C. At least one hypomanic episode and at least one major depressive episode are not better explained by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. *Indicate specifiers if applicable DIAGNOSTIC CRITERIA FOR CYCLOTHYMIC DISORDER A. For at least two (2) years (at least one year in children and adolescents), there have been numerous periods with hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), Criterion A symptoms have been present for at least half the time, and the individual has not been without the symptoms for more than two (2) months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum D. and other psychotic disorders. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With anxious distress The causes of mood disorders lie in a complex interaction of biological, psychological, and social factors. From a biological perspective, researchers are particularly interested in the stress hypothesis and the role of neurohormones. Psychological theories of depression focus on learned helplessness and the depressive cognitive schemas, as well as interpersonal disruptions. A variety of treatments, both biological and psychological, have proved effective for mood disorders, at least in the short term. For those individuals who do not respond to antidepressant drugs or psychosocial 05 Handout *Property of STI  [email protected] Page 8 of 9  AS2402 treatments, a more dramatic physical treatment, electroconvulsive therapy, is sometimes used. Two psychological treatments—cognitive therapy and interpersonal psychotherapy—seem effective in treating depressive disorders. Relapse and recurrence of mood disorders are common in the long term, and treatment efforts must focus on maintenance treatment —that is, on preventing relapse or recurrence. Treatment for mood disorders is most effective and easiest when it’s started early. Most people are treated with a combination of methods. Suicide is often associated with mood disorders but can occur in their absence or the presence of other disorders. It is the 10th leading cause of death among all people in the United States, but among adolescents, it is the 3rd leading cause of death. In understanding suicidal behavior, three indices are important: suicidal ideation (serious thoughts about suicide), suicidal plans (a detailed method for killing oneself), and suicidal attempts (that are nonfatal). Important, too, in learning about risk factors for suicides is the psychological autopsy, in which the psychological profile of an individual who has died by suicide is reconstructed and examined for clues. References American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th Ed., text rev.) Barlow, D., Durand, V., Hofmann, S. (2023). Psychopathology: An Integrative Approach to Mental Disorders (9th Ed). Cengage. 05 Handout *Property of STI  [email protected] Page 9 of 9