Chapter 7: Depressive and Bipolar Disorders Abnormal Psychology

Clinicians diagnose people who have manic episodes with bipolar disorder, a term that has replaced

"manic depression." An individual must experience a manic episode in order for a clinician to diagnose bipolar disorder.

Supporting the role of genetics, it has long been known that first-degree relatives of people with major depressive disorder are

15 to 25 percent more likely to have the disorder than are people who do not have this close biological relationship. Based on the existing literature, major depressive disorder has an estimated heritability of 37 percent, with rates higher in women than men (approximately 40 percent for women vs. 30 percent for men).

In the United States, the lifetime prevalence of major depressive disorder is

16.6 percent of the adult population. The 1-year prevalence of a major depressive episode is estimated to be 6.7 percent of all adults in the United States, or 16.2 million, individuals.

Second only to lower back pain as a cause of years lived with disability around the world, major depressive disorder is also the

19th most common global disease

Antidepressant medications take time to work, requiring

2 to 6 weeks to take effect. Once the depression has subsided, the clinician will urge the client to remain on the medication for 4 or 5 additional months, and much longer for people with a history of recurrent, severe depressive episodes. It is best for the clinician and client to work together to develop therapeutic programs that include regular visits early in treatment, expanded educational efforts that focus on the medications, and continued monitoring of treatment compliance.

Bipolar disorder has a lifetime prevalence rate of

3.9 percent in the U.S. population and a 12-month prevalence of 2.6 percent.

The highest suicide rates by age are for people

45 to 54 years old (20.3 per 100,000). Individuals 85 and older have the next highest rates (19.4) as well as the highest rates of suicide by discharge of firearms (13.7). Within the United States, white men are much more likely than are nonwhite men to commit suicide.

Of those diagnosed with bipolar disorder in a given year, nearly

83 percent (2.2 percent of the adult population) have cases classified as severe. At least half of all cases begin before a person reaches the age of 25

Young adults are at highest risk of suicide in many countries outside the United States. In Europe and North America, depression and alcohol-use disorders are major psychological risk factors for suicide. In the United States, more than

90 percent of suicides occur in people with a psychological disorder (Goldsmith et al., 2002). In contrast, impulsiveness plays a higher role in the suicides of people from Asian countries (World Health Organization, 2011).

Cyclothymic disorder

: A mood disorder with symptoms that are more chronic and less severe than those of bipolar disorder. characterized by alternations between dysphoria and briefer, less intense, and less disruptive euphoric states called hypomanic episodes. People with this disorder have met the criteria for a hypomanic episode many times over a span of at least 2 years (1 year in children and adolescents) and also experience numerous periods of depressive symptoms but never meet the criteria for a major depressive episode. During their respective time frames, adults, children, or adolescents have never been without these symptoms for more than 2 months at a time.

Disruptive mood dysregulation disorder

A depressive disorder in children who exhibit chronic and severe irritability and have frequent temper outbursts that occur, on average, three or more times per week over at least 1 year and in at least two settings. These outbursts must be developmentally inappropriate, meaning that, for example, in an older child or young teen they take the form of the behavior of a much younger child. Between outbursts, children with this disorder remain angry or at least extremely irritable. The criteria specify that the diagnosis should not be made for the first time for children whose first episode occurs when they are younger than 6 or older than 18. However, either by directly observing the child or from the child's history, the clinician must determine that the disorder had its onset before the age of 10. In other words, a teen of 13 must be reported by parents or teachers, for example, to have been subject to angry episodes prior to turning 10 years old.

Depressive Disorder

A disorder characterized by periods in which, among other symptoms, an individual experiences an unusually intense sad mood.

Major depressive disorder

A disorder in which the individual experiences acute but time-limited episodes of depressive symptoms.

Euphoria

A feeling state that is more cheerful and elated than average, possibly even ecstatic.

Bipolar disorder, rapid cycling

A form of bipolar disorder involving four or more episodes within the previous year that meet the criteria for manic, hypomanic, or major depressive disorder. In some individuals, the cycling may occur within 1 week or even 1 day. The factors that predict rapid cycling include earlier onset, higher depression scores, higher mania scores, and lower global assessment of functioning. A history of rapid cycling in the previous year and use of antidepressants also predict rapid cycling. Medical conditions such as hypothyroidism, disturbances in sleep/wake cycles, and use of antidepressant medications can also contribute to the development of rapid cycling. Individuals who experience bipolar disorder, rapid cycling are at higher risk of suicide than others with bipolar disorder, and also of a longer duration of the disorder

Bipolar disorder

A mood disorder involving manic episodes—intense and disruptive experiences of heightened mood, possibly alternating with major depressive episodes.

Major depressive episode

A period in which the individual experiences intense psychological and physical symptoms accompanying feelings of overwhelming sadness (dysphoria).

Hypomanic episode

A period of elated mood not as long as a manic episode.

Interpersonal therapy (IPT)

A time-limited form of psychotherapy for treating people with major depressive disorder, based on the assumption that interpersonal stress induces an episode of depression in a person who is genetically vulnerable to this disorder. Clinicians administer interpersonal therapy in three broad phases. In the first phase, the clinician assesses the magnitude and nature of the individual's depression using quantitative assessment measures and semistructured interviews. Depending on the type of depressive symptoms the individual shows, the therapist may consider combining treatment with antidepressant medications along with psychotherapy. In the second phase, the therapist and the client collaborate on formulating a treatment plan that focuses on the primary problem. Typically, these problems are related to grief, interpersonal disputes, role transitions, and problems in interpersonal relationships stemming from inadequate social skills. The therapist then carries out the treatment plan in the third phase, varying the methods according to the precise nature of the client's primary problem. The IPT approach encourages clinicians to combine such techniques as encouraging self-exploration, providing support, educating the client on the nature of depression, and offering feedback on the client's ineffective social skills. A primary focus of therapy is on the here and now, rather than on past childhood or developmental issues.

Cognitive triad

According to the cognitive theory of depression, the view that a depressed person's dysphoria results from a negative view of the self, the world, and the future.

Manic episode

Acute but the time-limited period of intense and unusual elation.

Dysphoria

An unusually elevated sad mood.

Behavioral activation

Behavioral therapy for depression in which the clinician helps the client identify activities associated with positive mood. The client keeps a record of the frequency of engaging in these rewarding activities and sets small weekly goals that gradually increase in frequency and duration. These activities are preferably consistent with the client's core values. Some clients may prefer to explore the arts, whereas others spend time in physical activity. Behavioral activation seems particularly well suited for clients who are not "psychologically minded," for group therapy, and for settings such as hospitals, nursing homes, and substance abuse treatment centers

Circadian rhythms

Biological clocks that set patterns of sleepfulness and wakefulness on approximately a 24-hour basis. Such treatments include light therapy, in which the individual is seated in front of a bright light for a period of time, such as 30 minutes in the morning. One distinct advantage of light therapy is that its side effects are minimal and almost entirely disappear after the dosage is reduced or treatment discontinued (Pail et al., 2011). Researchers also believe lithium may work on at least some individuals with bipolar disorder by resetting their circadian rhythms.

Premenstrual dysphoric disorder (PMDD)

Changes in mood, irritability, dysphoria, and anxiety that occur during the premenstrual phase of the monthly menstrual cycle and subside after the menstrual period begins for most of the cycles of the preceding year. This disorder was in the Appendix (it was not a diagnosable condition) in DSM-IV-TR. By making this disorder part of the standard psychiatric nomenclature, the DSM-5 authors believed that better diagnosis and treatment could result for women who experience its symptoms.

Persistent depressive disorder (dysthymia)

Chronic but less severe mood disturbance in which the individual does not experience a major depressive episode. People with persistent depressive disorder (dysthymia) have, for at least 2 years (1 year for children and adolescents), a more limited set of the symptoms that occur with major depressive disorder, including sleep and appetite disturbances, low energy or fatigue, low self-esteem, difficulty with concentration and decision making, and feelings of hopelessness. However, people with persistent depressive disorder currently do not meet the criteria for a major depressive episode. Despite the fact that people with persistent depressive disorder do not experience all the symptoms of a major depressive episode, they are never free of their symptoms for longer than 2 months. Moreover, they are likely to have other serious psychological disorders, including a heightened risk for developing major depressive disorder, personality disorder, and substance use disorder.

For most of the time during a 2-week period, a person experiences at least five or more of the first nine symptoms in addition to the last two. He or she must experience a change from previous functioning, and at least one of the first two symptoms must be present. During this 2-week period, most of these symptoms must be present nearly every day.

Depressed mood most of the day Markedly diminished interest or pleasure in all or most daily activities Significant unintended weight loss or unusual increase or decrease in appetite Insomnia or hypersomnia Psychomotor agitation or retardation observable by others Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Difficulty maintaining concentration or making decisions Recurrent thoughts of death or having suicidal thoughts, plans, or attempts The symptoms are not attributable to a medical condition or use of a substance The symptoms cause significant distress or impairment

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy must last at least 1 week and the symptoms must be present most of the day, nearly every day (or for any duration if hospitalization is necessary).

During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms are present to a significant degree (four if the mood is only irritable) and represent a noticeable change from usual behavior: inflated self-esteem or grandiosity decreased need for sleep (the client feels rested after, say, only 3 hours of sleep) more talkative mood than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility (attention is too easily drawn to unimportant or irrelevant external stimuli), as reported or observed increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation excessive engagement in activities that have high potential for painful consequences (such as unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Pharmacogenetics

The use of genetic testing to identify who will and will not improve with a particular medication.

Even with the best treatment, between 60 and 70 percent of individuals with major depressive disorder do not

achieve symptom relief

The focus of cognitive-behavioral therapy (CBT) is on helping clients try to change their dysfunctional thought processes that in turn will improve their mood. Like behaviorally oriented therapy, CBT requires an

active collaboration between the client and the clinician. In contrast to behaviorally oriented therapy, however, CBT also focuses on the client's dysfunctional thoughts and how to modify them through cognitive restructuring. Mindfulness training, as an additional component of a cognitive-behavioral intervention, can help clients develop a greater sense of self-efficacy, an added boost to its positive effects on mood. Another CBT technique known as mood monitoring can further help clients learn ways to track their mood over time and look for patterns in mood fluctuation. This is particularly helpful in the case of clients with bipolar disorder, who through the mood monitoring technique become more self-aware of when their symptoms might be worsening, so they can intervene using skills or other methods to avoid a full-blown manic or depressive episode.

TCAs, which derive their name from the fact that they have a three-ring chemical structure, include

amitriptyline (Elavil, Endep), desipramine (Norpramin), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). These medications are particularly effective in alleviating depression in people who have some of the more common biological symptoms, such as disturbed appetite and sleep. Although the exact process by which TCAs work remains unclear, we do know that they block the premature reuptake of biogenic amines back into the presynaptic neurons, thus increasing their excitatory effects on the postsynaptic neurons.

Because of the variable nature of the bipolar disorder, other medications can be beneficial in treating symptoms apart from the mania itself. For example, people in a depressive episode may need to take an

antidepressant medication in addition to the lithium for the duration of the episode. However, this can be problematic for a person who is prone to developing mania, because an antidepressant might provoke hypomania or mania. Those who have psychotic symptoms may benefit from taking antipsychotic medication such as clozapine (Li, Tang, Wang, & de Leon, 2015). People who experience rapid cycling present a challenge for clinicians because of the sudden changes that take place in their emotions and behavior.

Brain scan and neuropsychological testing of individuals with bipolar disorder suggest that they have difficulties in

attention, memory, and executive function consistent with abnormalities in the prefrontal lobe

The two major categories of bipolar disorder are

bipolar I and bipolar II. A diagnosis of bipolar I disorder describes a clinical course in which the individual experiences one or more manic episodes with the possibility, although not the necessity, of experiencing one or more major depressive episodes. In contrast, a diagnosis of bipolar II disorder means the individual has had one or more major depressive episodes and at least one hypomanic episode. The criteria for a hypomanic episode are similar to those for a manic episode but require a shorter duration (4 days instead of 1 week).

Clinicians and clients are not sure exactly how ECT works, but most current hypotheses center on ECT-induced changes in neurotransmitter receptors and in the body's natural opiates which, in turn,

cause structural changes in the brain

People with bipolar disorder are also at risk of more severe

chronic health problems than others their own age. They have higher rates of heart disease and diabetes and higher levels of cholesterol.

Psychoanalytic explanations of bipolar disorder propose that manic episodes are

defensive responses through which individuals stave off feelings of inadequacy, loss, and helplessness. Clients are thought to develop feelings of grandiosity and elation or become hyperenergetic as an unconscious defense against sinking into a state of gloom and despair. Supporting this interpretation, researchers report a positive relationship between use of denial and narcissistic defense mechanisms and the extent of manic symptoms.

Suicidal behavior runs along a continuum of thinking about ending one's life ("suicidal ideation"), to

developing a plan, to undertaking nonfatal suicidal behavior ("suicide attempt"), to actually ending one's life ("suicide").

One of the major problems in the DSM-IV-TR was a failure to differentiate these episodes from a person's typical level of activity, sadness, or disturbance. In particular, the failure to

distinguish bipolar disorder from attention-deficit/hyperactivity disorder might, in turn, have led to overdiagnosis of children and adolescents with bipolar disorder. Thus, the changes represent a slight but important improvement and will lead to greater specificity.

Clinicians are increasingly integrating behavioral with cognitive approaches that focus on the role of

dysfunctional thoughts as causes of, or at least contributors to, mood disorders. People with depressive disorders, according to the cognitive-behavioral perspective, think in repetitively negative ways that perpetuate their negative emotions.

According to the sociocultural perspective, individuals develop depressive disorders in response to

external life circumstances. These circumstances can be specific events such as sexual victimization, chronic stress such as poverty and single parenting, or episodic stress such as bereavement or job loss. Women are more likely to be exposed to these stressors than are men, a fact that may account, at least in part, for the higher frequency in the diagnosis of depressive disorders in women.

Individuals who are in a manic, hypomanic, or major depressive episode may show features of the opposite pole but not to an

extreme enough degree to meet the relevant diagnostic criteria for bipolar disorder. For example, people in a manic episode may also report feeling sad or empty, fatigued, or suicidal. DSM-5 uses a specifier of "mixed features" to apply to cases in which an individual experiences episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present. The "mixed" category accounts for individuals with bipolar disorder who may show features of both depression and mania/hypomania, either simultaneously or nearly simultaneously.

SSRIs block the uptake of serotonin, making more of this crucial neurotransmitter available to act at the receptor sites of receiving neurons. SSRIs include

fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and sertraline (Zoloft). Balancing their positive effects on mood are their side effects. The most commonly reported are nausea, agitation, and sexual dysfunction. A newer class of antidepressants are serotonin modulators (such as vortioxetine) that target the postsynaptic serotonin receptors rather than the reuptake of serotonin in the synapse. These medications were approved for use in the United States in 2013, and results are still coming in on whether they will prove to be as effective as, but with fewer side effects than, other classes of antidepressants.

The biopsychosocial perspective is particularly appropriate for understanding why people commit suicide and in many ways parallels the understanding gleaned from an integrative framework for major depressive disorders. Biological theories emphasize the

genetic and physiological contributions that also contribute to the causes of mood disorders. Psychological theories focus on distorted cognitive processes and extreme feelings of hopelessness that characterize suicide victims. From a sociocultural perspective, the variations between and within countries suggest contributions relating to an individual's religious beliefs and values and the degree to which the individual is exposed to life stresses.

Interpersonal and social rhythm therapy (IPSRT) (Frank, 2007) is a biopsychosocial approach to treating people with bipolar disorder that

incorporates the concepts of stressful life events and disturbances in circadian rhythms (such as altered sleep/wake cycles, appetite, and energy level) into a focus on the individual's personal relationships. According to the IPSRT model, mood episodes are likely to emerge from medication nonadherence, stressful life events, and disruptions in social rhythms.

Contemporary approaches to treatment within the psychodynamic perspective focus on helping

individuals manage their symptoms rather than attempting to repair the core of the individual's disturbed attachment. These approaches consist of short (8- or 10-session), focused treatments. A review of eight studies comparing short-term psychodynamic therapy to other methods showed this method to be as least as effective as CBT in the treatment of major depressive disorder.

Even though these medications can be effective, especially for certain clients, researchers are concerned that studies of antidepressants suffer from the "file drawer problem"—the fact that

investigators are likely to file away, and not even submit for publication, studies that fail to establish significant benefits. In one analysis of 74 FDA-registered studies on antidepressants, 31 percent, accounting for 3,349 study participants, were not published. On the other hand, in the published studies, 94 percent of the medication trials reported positive findings. This bias toward publishing only positive results severely limits our ability to evaluate the efficacy of antidepressants because we are seeing only a slice of the actual data.

Psychoeducation is an especially important aspect of treating people with bipolar disorder to help them understand

its nature, as well as the reasons medication is so important in controlling symptoms.

The traditional treatment for bipolar disorder is

lithium carbonate, referred to as lithium, a naturally occurring salt found in small amounts in drinking water that, when used medically, replaces sodium in the body. Clinicians advise people who have frequent manic episodes (two or more a year) to remain on lithium continuously as a preventive measure. The drawback is that, even though lithium is a natural substance in the body, it can have side effects. These include mild central nervous system disturbances, gastrointestinal upsets, and more serious cardiac effects. As a consequence, people who experience manic episodes may be reluctant or even unwilling to take lithium continuously

deep brain stimulation (DBS) is another somatic treatment clinicians use to target

major depressive disorder (as well as obsessive-compulsive disorder and movement disorders).

Antidepressant medication is commonly prescribed to individuals who suffer from

major depressive disorder.

Although not a diagnosable disorder, suicidality is one potential diagnostic feature of a

major depressive episode. The definition of suicide is "a fatal self-inflicted destructive act with explicit or inferred intent to die"

Critics argue that the PMDD diagnosis pathologizes the normal variations in mood that can occur over the course of a woman's monthly menstrual cycle. However, the counterargument is that the

majority of women do not experience monthly mood alterations so severe that they would show such extreme symptoms. Including PMDD as a diagnosis allows those with these severe episodes of depression to receive treatment that might not otherwise be available to them.

From the client's perspective, lithium can be seen to interfere with the euphoria that can accompany the beginnings of a

manic episode. Consequently, people with this disorder who enjoy those pleasurable feelings may resist taking the medication. Unfortunately, by the time their euphoria escalates into a full-blown episode, it is often too late because their judgment has been clouded by their manic symptoms of grandiosity and elation. To help overcome this dilemma, clinicians may advise their clients to participate in lithium groups, in which members who use the medication on a regular basis provide support to each other and reinforce the importance of staying on the medication.

Moving from genetics to the biochemical abnormalities, increasing evidence points to the role of altered serotonin and norepinephrine levels in causing the mood changes associated with major depressive disorder. However, not everyone with a genetic predisposition shows these

mood-changing alterations in neurotransmitter levels. If exposed as adults to life stressors and other environmental factors, the genetically predisposed can experience a series of changes in the neural pathways active in regulating mood. Contributing further to their chances of developing depression are abnormalities in brain-derived neurotrophic factor (BDNF), a protein that helps keep neurons alive and able to adapt and change in response to experience.

At present, biological interventions for mood disorders target not the genetic abnormalities themselves but the effect of those abnormalities on

neurotransmitters. Therefore, antidepressant medication is the most common form of biologically based treatment for people with major depressive disorder. Clinicians prescribe antidepressants from four major categories: selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). The choice of antidepressants depends primarily on the clinician's preference for a particular class of medications. Ultimately, the medications the individual receives may be selected by trial and error as the clinician attempts to identify which work best and produce the fewest side effects.

Compared to major depressive disorder, bipolar disorder has an even stronger

pattern of genetic inheritance, with an estimated heritability of 60 to as high as 85 percent

Of all psychological disorders, bipolar disorder is the most likely to occur in

people who also have problems with substance abuse. People with both bipolar and substance use disorders have an earlier onset of bipolar disorder, more frequent episodes, and higher risk of developing anxiety- and stress-related disorders, aggressive behavior, problems with the law, and risk of suicide

Major depressive disorder can be diagnosed with a range of other disorders including, for example

personality disorders, substance use disorders, and anxiety disorders. A number of conditions can mimic major depressive disorder. These include schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder. The clinician must rule out these specific disorders before assigning the diagnosis of major depressive disorder to the client.

Long aware of the tendency for mood disorders to occur more frequently among biologically related family members, researchers working within the biological perspective are attempting to

pinpoint genetic contributors to these disorders. However, multiple genes interact with environmental risk factors in complex ways, with epigenetics playing a significant role.

The factors that seem to contribute to high resilience include the ability to make

positive assessments of your life circumstances and to feel in control over these circumstances. Additional buffers to suicide risk are a number of psychosocial factors such as being able to solve problems, having high self-esteem, feeling supported by family and significant others, and being securely attached. People who do not believe suicide is an acceptable option to stress are also better able to overcome high risk. On the negative side, low resilience occurs with high levels of perfectionism and hopelessness (Hewitt, Caelian, Chen, & Flett, 2014). Having friends or family members who attempted suicide represents another risk factor.

SNRIs increase both norepinephrine and serotonin levels by blocking their

reuptake. They include duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq). These medications also carry with them a number of undesirable side effects including suicidal thoughts or attempts as well as allergic symptoms, gastrointestinal disturbances, weakness, nausea, vomiting, confusion, memory loss, irritability, and panic attacks, among others. Compared to SSRIs, the SNRIs show statistically significant effects in experimental studies, but clinically they seem to hold no advantages. If anything, SNRIs bring a higher risk of adverse reactions than SSRIs.

Early psychoanalytic theories based on the psychodynamic approach proposed that people with depressive disorders had suffered a loss early in their lives that affected them at a deep, intrapsychic level (Abraham, 1911/1968). It was attachment theory, however, that focused attention on people's feelings of

security or insecurity arising from the way their caregivers reared them in childhood. Bowlby (1980) proposed that people with an insecure attachment style have a greater risk for developing a depressive disorder in adulthood. Following up on Bowlby's ideas, Bemporad (1985) proposed that insecurely attached children become preoccupied with the need to be loved by others. As adults, they form relationships in which they overvalue the support of their partners. When such relationships end, they become overwhelmed with feelings of inadequacy and loss.

The antidepressant effects of MAOIs, such as phenelzine (Nardil) and tranylcypromine (Parnate), prolong the life of

serotonin and norepinephrine in the synapse, thereby increasing their actions in the central nervous system. MAOIs are particularly effective in treating chronic depression in people who have not responded to other medications. However, they have serious side effects that can be life-threatening when people taking them are also on allergy medications or ingest foods or beverages such as beer, cheese, and chocolate, all of which are high in a substance called tyramine. As a result, clinicians do not prescribe MAOIs as commonly as other types of antidepressant medications.

One of the earliest behavioral formulations of theories of depression regards the

symptoms of depression as resulting from lack of positive reinforcement (Lazarus, 1968; Skinner, 1953). According to this view, depressed people withdraw from life because they no longer have incentives to be active. Contemporary behaviorists base their approach on Lewinsohn's (1974) model. Lewinsohn maintained that depressed people have a low rate of what he termed "response contingent positive reinforcement behaviors," which increase in frequency as the result of performing actions that produce pleasure. According to the behaviorist point of view, the lack of positive reinforcement elicits the symptoms of low self-esteem, guilt, and pessimism.

Rather than using one therapeutic approach, then, clinicians currently recommend the use of a combination of methods ranging from

traditional psychotherapeutic medications to mindfulness training, and even nutritional supplements and hormone therapy. They are also now turning to cognitive remediation therapy, based on the findings in the literature of cognitive abnormalities in memory, inhibitory control, and attention.

The perspective of positive psychology provides a framework for

understanding why individuals who are at high risk for the reasons above nevertheless do not commit suicide. The buffering hypothesis of suicidality (Johnson et al., 2011) describes resilience as a separate dimension from risk. You may be at risk of committing suicide, but if you are high on resilience, you are unlikely to do so. The statistically higher risk you may face due to living in a stressful environment may not translate into higher suicidality if you feel you can cope successfully with these circumstances.

Medication is certainly one route for the clinician to follow in treating individuals

with major depressive disorder. However, increasing attention is being given to the possibility that psychotherapy can be equally effective. Psychotherapy also carries fewer risks and adverse side effects than medication use. Over the long term, it could therefore be a better treatment route with more enduring effects than medication (Hollon, 2016). This is possible in part because, through therapy, individuals can work through some of their underlying issues and also learn skills for managing their symptoms that they can continue using on their own.