Chapter 7: Depressive and Bipolar Disorders and Suicide

Emile Durkheim (1858-1917)

A French sociologist who studied people and their relationship to society. He believed some people commit suicide for different reasons related to social integration.

Grandiosity

A belief that a person is especially powerful or talented when this is not actually true.

Monoamine oxidase inhibitors (MAOIs)

A class of antidepressant drug that inhibits monoamine oxidase, which breaks down neurotransmitters, to increase levels of those neurotransmitters.

Tricyclic antidepressants

A class of antidepressant medication that affects different neurotransmitter systems and often comes with many side effects.

Selective serotonin reuptake inhibitors (SSRIs)

A class of antidepressant medication that specifically affects serotonin levels and has fewer side effects than other antidepressants.

Premenstrual dysphoric disorder

A controversial condition that refers to depressive or other symptoms during most menstrual cycles in the past year. A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to IMPROVE within a few days after the onset of menses, and become MINIMAL or absent in the week postmenses. B. One (or more) of the following symptoms must be present: 1. Marked affective lability. 2. Marked irritability or anger or increased interpersonal conflicts. 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge. C. One (or more) of the following symptoms must additionally be present, to reach a total of FIVE symptoms when combined with symptoms from Criterion B above. 1. Decreased interest in usual activities. 2. Subjective difficulty in concentration. 3. Lethargy, easy fatigability, or marked lack of energy. 4. Marked changes in appetite; overeating; or specific food cravings. 5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control. 7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, sensation of "bloating," or weight gain. Note: The symptoms is Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year. D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships. E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles (Note: The diagnosis may be made provisionally prior to this conformation). G. The symptoms are not attributable to the physiological effects of a substance or another medical condition. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Persistent depressive disorder (dysthymia)

A depressive disorder involving a chronic feeling of depression for at least 2 years. A. Depressed mood for most of the day, more days than not, as indicated by either subjective account or observations by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 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 Criterion A and B for more than 2 months at a time. D. Criteria for a major depressive disorder must be continuously present for 2 years. E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorder. 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., hyperthyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if in partial or full remission, early (before age 21 years) or late (after age 21 years), and mild, moderate, or severe. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Hopelessness

A feeling of despair often related to severe depression and suicide.

Bipolar II disorder

A mental disorder marked by episodes of hypomania that alternate with episodes of major depression. A. Criteria have been met for at least one hypomanic episode (Criteria A-F under "Hypomanic Episode") and at least one major depressive episode (Criteria A-C under "Major Depressive Episode"). B. There has never been a manic episode. C. The occupancy of the hypomanic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. 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. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association

Cyclothymic disorder (cyclothymia)

A mental disorder marked by fluctuating symptoms of hypomania and depression for at least two years. A. For at least two years (at least one year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for major depressive episode. B. During the above two year period (One year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than two months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. C. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance or another medical condition. D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association

Major depressive disorder (major depression/unipolar depression)

A mental disorder marked by multiple major depressive episodes. A. Five (or more) of the following symptoms have been present during the same 2-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 that are clearly 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, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood). 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 every day (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 or 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 to another medical condition. Note: Criteria A-C represents a major depressive episode. Note: Responses to a significant loss may include the feelings of intense sadness, rumination about the loss, 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. The decision inevitably requires the exercise of clinical judgement based on the individual's history and the cultural norms for the expression of the distress in the context of loss. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or 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. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Bipolar I disorder (manic-depression)

A mental disorder marked by one or more manic episodes. A. Criteria have been met for at least one manic episode (Criteria A-D under "Manic Episode"). B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association

Depressive disorder

A mental disorder marked by substantial sadness and related characteristic symptoms.

Bipolar disorder

A mental disturbance sometimes characterized by depression and mania.

Hypomanic episode

A period during which a person experiences manic symptoms but without significant interference in daily functioning. A. 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. 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) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree: 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility, as reported or observed. 6. Increase in goal-directed activity or psychomotor agitation. 7. Excessive involvement in activities that have high potential for painful consequences. 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 the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance Note: A full hypomanic episode that emerged during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndrome level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Manic episode

A period during which a person feels highly euphoric or irritable. A. 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 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. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility, as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities that have high potential for painful consequences. 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 or to another medical condition. Note: A full manic episode that emerged during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndrome level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Major depressive episode

A period of time, two weeks or longer, marked by sad or empty mood most of the day, nearly every day, and other symptoms.

Electroconvulsive therapy (ECT/shock therapy)

A procedure in which an electrical current is introduced to the brain to produce a seizure to alleviate severe depression.

Repetitive transcranial magnetic stimulation (rTMS)

A procedure to treat depressive and bipolar disorders that involves rapidly changing magnetic field's.

Hopelessness (attribution) theory

A theory of depression that people are more likely to become depressed if they make global, internal, and stable attributions about negative life events.

Learned helplessness

A theory related to depression that people act in a helpless, passive fashion upon learning their actions have little effect on the overall environment.

Eclectic approach

An approach that uses techniques from different theoretical orientations such as psychodynamic, cognitive, behavioral, and family systems approaches.

Euphoria

An intense state of happiness.

Schematic for assessment of suicidality

Assess sociodemographic risk factors: Elderly, unmarried, white, male, living alone. Ask about stressors: "How are things going in your marriage, in your family, at home, at work?" (Cover help, financial, marital, family, legal, and occupational factors). Screen for depression and associated anxiety or agitation: "Have you experienced sad, blue, or empty feelings and at least two of the following in the past two weeks: • Trouble falling or staying asleep. • Feeling tired or having little energy. • Poor appetite or overeating. • Little interest or pleasure in doing things. • Feeling bad about yourself. • Trouble concentrating. • Feeling fidgety, restless, or unable to sit still." "Have you ever felt nervous, anxious, or on edge?" "Have you had anxiety or panic attacks recently?" Screen for excessive alcohol use: "Have you ever felt you should cut down on your drinking?" "Have people annoyed you by criticizing your drinking?" "Have you ever felt bad or guilty about your drinking?" "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" Yes to two or more means probable excessive alcohol use. Assess risk of suicide: "Have you had thoughts about death, or about killing yourself?" If yes, ask: "Do you have a plan for how you would do this?" "Are there means available (e.g., a gun and bullets or poison)?" "Have actually rehearsed or practiced how you would kill yourself?" "Do you tend to be impulsive?" "How strong is your intent to do this? "Can you resist the impulse to do this?" "Have you heard voices telling you to hurt or kill yourself? Ask about previous attempts, especially the degree of intent. Ask about suicide of family members.

1. Interviews and clinician ratings. 2. Self-report questionnaires 3. Self-monitoring and observations from others 4. Laboratory assessment 5. Assessment of suicide

Assessment techniques of depressive and bipolar disorders and suicide

Global

Assuming that an event will affect most areas of one's life.

Stable

Assuming that an event will last a long time.

Sample developmental pathway of depression

Biological Vulnerabilities/Early Predispositions: Genetic contributions, neurochemical and hormonal changes, brain changes lead to... Early Family Problems: Poor attachment, disengaged parents, expressed emotion, modeling of parental depression lead to... Stressful Life Events: Family conflict, alienation from others, academic and other challenges lead to... Cognitive-stress and Behavioral Vulnerabilities: Sense of learned helplessness and hopelessness, intense negative emotions and arousal, escape-oriented behavior, lack of social support leads to... Possible depression.

Endogenous

Biologically oriented.

Common mood-stabilizing medications for people with bipolar disorder

Carbamazepine (Tegretol), Divalproex (Depakote), Lamotrigine (Lamictal), Lithium (Eskalith), Olanzapine (Zyprexa), Thorazine (Chlorpromazine).

Sample Items from the Children's depression inventory

Choose one: • am sad once in a while. • am sad many times. • am sad all the time. Choose one: • do not think about killing myself. • think about killing myself, but I would not do it. • want to kill myself. Choose one: • nobody really loves me. • am not sure if anybody loves me. • am sure that somebody loves me.

Negative cognitive triad

Cognitive distortions involving the self, world, and the future. Example— Negative view of self: "I'm Stupid." Negative view of future: "I'll have to drop out of school." Negative view of world: "Everyone will think I'm a failure."

Automatic thoughts

Cognitive distortions of the negative cognitive triad that are constantly repeated and often associated with depression.

Ultradian cycling

Continuous cycling.

1. Many older people with depression focus on complaints of physical symptoms of their depression rather than mood. 2. Symptoms of depression such as withdrawal or motivation loss may be thought of by others as a desire to relax during retirement or simply signs of "old age." 3. Symptoms of sadness may be dismissed as simple bereavement over friends to begin to pass away. 4. Symptoms of depression often mimic those seen in dementia, especially slowed speech and movement and difficulties in memory and concentration. What may initially appear to be Alzheimer's disease may actually be depression.

Depression among the elderly is sometimes difficult to detect for what four reasons?

Seasonal depression

Depression in some people that occurs more in fall and winter months.

Screening questions for depressive and bipolar disorder

Do you find any of the mood symptoms described in this chapter apply to you much more so than most people your age? Are there many things you would like to do but cannot because you feel too sad? Are you greatly troubled by your mood symptoms? Do other people notice your sadness or euphoria or encourage you to seek help? Does your sadness or euphoria last much of the time, even with nothing stressful is happening? Has your work or social life or sleep suffered a lot because of sadness or euphoria? Do you get extremely upset upset over even little things most of the time? Have you experienced a stressful life event that you just cannot seem to put behind you? Do you feel sad, irritable, tense, and pessimistic much of the time? If you could make your life better, would it include feeling less sad?

Nonmaleficence

Does the procedure harm the person in any way?

Beneficence

Does the procedure help the person?

Justice

Does the procedure preserve the person's dignity?

Systemic disorders

Endocrine disorders: Hypothyroidism and hyperthyroidism, adrenal diseases (Cushing's, Addisons), parathyroid disorders. Inflammatory/infectious diseases: Systemic lupus erythematosus, neurosyphilis, AIDS, tuberculosis, mononucleosis, Sjögren's syndrome, chronic fatigue syndrome. Metabolic disorders: Uremia, porphyria, vitamin deficiencies. Miscellaneous disorders: Medication side effects, chronic pain syndromes, sleep apnea, cancer, heart disease. (Disorders associated with depression)

Exogenous

Environmentally oriented.

Behavioral activation

Essential components of this include psychoeducation about depression, increasing daily activities and exercise, and rewarding progress. Specific activities a therapist may focus on include the following: • Education on creative activities, such as learning a musical instrument or engaging in photography. • Domestic activities, such as house cleaning or cooking. • Health and appearance activities, such as going to the dentist and shopping for new clothes. • Leisure activities, such as walking in the park and increased exercise. • Religious activities such as going to church.

Expressed emotion

Family interactions characterized by high levels of emotional over involvement, hostility, and criticism.

Neurological disorders

Focal lesions: Stroke, tumor, surgical ablation, epilepsy. Regional degenerative diseases: Parkinson's disease, Huntington's disease, Pick's disease, Fahr's disease, progressive supranuclear exposure, Wilson's disease. Diffuse diseases: Alzheimer's disease, AIDS dementia, multiple sclerosis. Miscellaneous disorders: Migraine, paraneoplastic syndromes. (Disorders associated with depression)

Rapid cycling

Frequently switching from depression to mania and back again with little or no period of normal mood.

Light therapy

Generally consists of having a person sit before a bright light of 2,000 to 10,000 lux (a unit of illumination) for 30 to 120 minutes per day during the winter.

1. Grief (due to the loss of a loved one). 2. Role disputes (with others such as a spouse, partner, parent, coworker, or friend). 3. Role transitions (or major changes in a person's life, such as ending a relationship, starting a new job, coping with an illness, or retiring from one's career). 4.Interpersonal deficits (such as a lack of social skill and trouble maintaining relationships with others).

IPT concentrates on what four main categories of relationship difficulty?

Hamilton Rating Scale for Depression

Instructions: For each item, select the number that corresponds to the statement that best characterizes the patient. 1. Depressed mood (sadness, hopeless, helpless, worthless) 0. Absent. 1. These feelings states indicated only on questioning. 2. These feeling states spontaneously reported verbally. 3. Communicates feeling states nonverbally-i.e., through facial expression, posture, voice, and tendency to weep. 4. Patient reports VIRTUALLY ONLY these feelings in their spontaneous verbal and nonverbal communication. 2. Feelings of guilt. 0. Absent. 1. Self reproach, feels they have let people down. 2. Ideas of guilt or rumination over past errors or sinful deeds. 3. Present illness is a punishment. Delusions of guilt. 4. Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations. 3. Suicide 0. Absent. 1. Feels life is not worth living. 2. Wishes they were dead or any thoughts of possible death to self. 3. Suicidal ideas or gestures. 4. Attempt at suicide (any serious attempt rates 4). 4. Insomnia early 0. No difficulty falling asleep. 1. Complains of occasional difficulty falling asleep-i.e., more than 1/2 hour. 2. Complains of nightly difficulty falling asleep. 5. Insomnia middle 0. No difficulty. 1. Patient complains of being restless and disturbed during the night. 2. Waking during the night—any getting out of bed rates 2 (except for purposes of voiding). 6. Insomnia late 0. No difficulty 1. Walking in the early hours of the morning but goes back to sleep. 2. Unable to fall asleep again if they get out of bed. From Hamilton M. (1967). Development of a rating scale for primary depressive illness, British Journal of Social & Clinical Psychology 6(4):278-296.

Reminiscence therapy

Involves a systematic review and discussion of each phase of a persons life, from birth to present, with a particular focus on trying to resolve conflicts and regrets.

Cognitive therapy

Involves examining a person's negative statements and encouraging them to challenge their thoughts.

Cognitive distortions

Irrational, inaccurate thoughts that people have about environmental events.

Respect for autonomy

Is the person fully informed of the benefits and risks of the procedure?

Symptom overlap between schizophrenia and bipolar disorder

Mania: • Irritability • Grandiosity • Euphoria Overlap: • Aggression • Agitation • Anxiety • Mood swings • Psychotic thinking • Anger • Impulsivity • Suicidal thoughts Schizophrenia: Negative Symptoms- •Affective flattening • Apathy Positive symptoms- • Delusions • Hallucinations

Social skills training

May help a person, especially an adolescent with depression, improve methods of social interaction, including making eye contact, smiling more, and discussing topics other than depression.

Self-control therapy

May involve having a person reinforce themselves for active, non-depressed behaviors.

Retrospective analysis (psychological autopsy)

May involve interviewing family members and friends, examining suicide notes, and evaluating medical records (Norra, Schaub, Juckel, & Schmieder, 2015).

Contingency management

May involve teaching significant others not to reinforce depressive behavior and instead reinforce active, prosocial behavior.

Coping or problem-solving skills training

Maybe used to help people find effective solutions for problems instead of avoiding them.

Mood-stabilizing drugs

Medications used to help people control rapid shifts in mood.

Emotions

Normal: Good Mood. Mild: Mild discomfort about the day, feeling a bit irritable or down. Moderate: Feeling upset and sad, perhaps becoming a bit teary-eyed. Depression—Less Severe: Intense sadness and frequent crying. Daily feelings of "heaviness" and emptiness. Depression—More Severe: Extreme sadness, very frequent crying, and feelings of emptiness and loss. Strong sense of hopelessness. (Continuum of sadness and depression)

Behaviors

Normal: Rising from bed, getting ready for the day, and going to school or work. Mild: Taking a little longer than usual to rise from bed. Slightly less concentration at school or work. Moderate: Coming home to slump into bed without eating dinner. Tossing and turning in bed, unable to sleep. Some difficulty concentrating. Depression—Less Severe: Inability to rise from bed many days, skipping classes at school, and withdrawing from contact with others. Depression—More Severe: Complete inability to interact with others or even leave the house. Great changes in appetite and weight. Suicide attempt or completion. (Continuum of sadness and depression) Normal: Normal daily activity. Mild: Completing daily tasks with great vigor. Being quite social and talkative. Moderate: Some difficulty sleeping due to sense of elation. Mania—Less Severe: Less need for sleep, pressure to talk continuously, working for hours on end. Mania—More Severe: Engaging in pleasurable activities that lead to damage, such as racing a car down a residential street or spending all of one's money. (Continuum of happiness, euphoria, and mania)

Cognitions

Normal: Thoughts about what one has to do that day. Thoughts about how to plan and organize the day. Mild: Thoughts about the difficulty of the day. Concern that something will go wrong. Moderate: Dwelling on the negative aspects of the day, such as a couple of mistakes on a test or a cold shoulder from a coworker. Depression—Less Severe: Thoughts about one's personal deficiencies, strong pessimism about the future, and thoughts about harming oneself (with little intent to do so). Depression—More Severe: Thoughts about suicide, funerals, and instructions to others in case if one's death. Strong intent to harm oneself. (Continuum of sadness and depression) Normal: Feeling good. Mild: Happiness about good events that day, such as an unexpected check in the mail. Feeling a "bounce" it one's step. Moderate: Sense of temporary euphoria and some grand life event such as a wedding or birth of a newborn. Feeling on "cloud nine". Mania—Less Severe: Intense euphoria for a longer period. Feelings of agitation and inflated self-esteem. Mania—More Severe: Extreme euphoria for very long periods, such as months. Sense of grandiosity about oneself, such as the belief that one is a great playwright. (Continuum of happiness, euphoria, and mania) Normal: Thoughts about the pleasant aspects of the day. Mild: Thoughts about good things in life. Moderate: Thoughts racing a bit about all the changes to one's life and how wonderful life is. Mania—Less Severe: Intense, racing thoughts that lead to distractibility and difficulty concentrating. Mania—More Severe: Racing thoughts almost nonstop that lead to complete inability to concentrate or speak to others coherently. (Continuum of happiness, euphoria, and mania)

Postpartum

Occurring after the birth of a child.

Peripartum

Occurring during pregnancy.

Unipolar

One pole.

Circadian rhythms

One's internal sleep-wake clock.

Hypersomnia

Oversleeping.

Suicide completion

People who do kill themselves.

1. People without any symptoms of the disorders. 2. People at risk for developing the disorders (such as children of parents with depressive disorders). 3. People who have a depressive disorder (and wish to prevent relapse).

Prevention programs for depressive disorders typically address what three things?

Altruistic suicide (Durkheim)

Refers to a situation in which a person commits suicide to benefit society or others around them. Think of a soldier who sacrifices their life in Afghanistan to save comrades (Braswell & Kushner, 2012).

Fatalistic suicide (Durkheim)

Refers to a situation in which a person feels oppressed by society and that their only means of escape is through death. Some people may feel condemned by fate, such as a woman who cannot have children—childlessness in women is indeed a risk factor for suicide attempt (Perry, 2016).

Anomic suicide (Durkheim)

Refers to a situation in which a person has great difficulty adapting to disrupted social order created by events such as economic crisis. A surge of suicide among elderly adults in China relate somewhat to massive economic changes there (Wang, Chan, & Yip, 2014).

Egoistic suicide (Durkheim)

Refers to a situation in which a person's social integration is weak, and so they believe committing suicide comes a little cost to others. Think of a teenager who believes no one cares for them—social alienation is indeed a risk factor for suicide (Barzilay et al., 2015).

Suicidal behavior (parasuicidal behavior/deliberate self-harm)

Refers to self-destructive behavior that may or may not indicate a wish to die. Examples include cutting and burning oneself.

Suicide attempt

Refers to severe self-destructive behavior in which a person is trying to kill themselves. Common methods of _____ _____ include firearms, hanging, alcohol/substance/medication overdose, carbon monoxide poisoning, and jumping from a high place.

Peripartum depression/postpartum depression

Refers to symptoms of depression or a major depressive episode that occurs during pregnancy or in the weeks after childbirth.

Suicidal ideation

Refers to thoughts about death, killing oneself, funerals, or other morbid ideas related to one's death. Thinking about suicide does not mean a person will commit suicide, but such thoughts can be a risk factor.

Distruptive Mood Dysregulation Disorder (DMDD)

Refers to youth aged 6 to 18 years with recurrent temper outbursts that are severe and well out of proportion to a given situation. A. Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times a week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others. E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D. F. Criteria A and D are present in at least two of three settings and are severe in at least one of these. G. The diagnosis should not be made for the first time before age 6 years or after age 18 years. H. By history or observation, the age at onset of Criteria A-E is before 10 years. I. There has never been a distinct period lasting more than 1 day during which the full system criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder. Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual had ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Commitment to a treatment statement

Represents an agreement between a therapist and client that the client will commit to the treatment process and to living, openly communicate about suicidal thoughts and urges, and access emergency care when needed (Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013).

Family studies

Researchers assess family members of a person with a mental disorder.

1. Genetics 2. Brain features (prefrontal and other cortical areas. Other areas of the brain. 3. Neurochemical and hormonal features (serotonin, norepinephrine, and dopamine for depression, dopamine and glutamate for bipolar). 4. Sleep deficiencies. 5. Stressful life events 6. Cognitive factors (cognitive distortions, negative cognitive triad, hopelessness theory, learned helplessness). 7. Interpersonal factors 8. Family factors 9. Cultural factors 10. Evolutionary influences.

Risk factors for depressive and bipolar disorders and suicide

Common medications for people with depression

Selective serotonin reuptake inhibitors (SSRIs): Citalopram (Celexa), Escitalopram oxalate (Lexapro), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft). Tricyclic antidepressants: Anafranil (Clomipramine), Elavil (Amitriptyline), Norpramin (Desipramine), Sinequan (Doxepin), Monoamine oxidase inhibitors (MAOIs): Marplan (Isocarboxazid), Nardil (Phenelzine), Parnate (Tranylcypromine). Others: Effexor (Venlafaxine), Wellbutrin (Bupropion), Remeron (Mirtazapine), Duloxetine (Cymbalta).

Polygenic transmission

Small sets of genes work interactively to cause a disorder.

• Declare existing strengths, such as being a good student or child. • Manage stress in difficult situations • Modify negative and irrational thoughts to think more realistically. • Solve problems effectively. • Develop and use social support networks such as friends and other social groups. • Develop strategies to reduce family and interpersonal conflict, such as negotiating solutions and repairing relationships. • Enhance social skill and recognize other people's perspectives.

The Resourceful Adolescent Program-Adolescents (RAP-A) involves an 11-session group approach to teach adolescents to...

Suicide

The act of killing oneself.

Interpersonal therapy (IPT)

The basis of this is that a person's attachment or relationships with others are key to mental health.

Mania

The far end of the happiness and euphoria continuum.

Depression

The far end of the sadness continuum.

Double depression

The presence of dysthymia AND a major depressive episode at the same time (Hellerstein & Eipper, 2013).

No-suicide contract

This is an agreement, often signed by a therapist and client, in which the client agrees to contact and speak with the therapist before any self-destructive act.

1. Mediation (antidepressants / SSRIs, tricyclics, and MAOIs for depression; mood-stabilizing drugs for bipolar disorder [biological perspective]. 2. ECT [biological perspective]. 3. rTMS [biological perspective]. 4. Light therapy [biological perspective]. 5. Behavioral activation and related therapies (contingency management, self-control therapy, social skills training, and coping or problem-solving skills training) [psychodynamic / behavioral approach]). 6. Cognitive therapy [cognitive perspective]. 7. Mindfulness [ cognitive perspective]. 8. IPT [cognitive perspective]. 9. Family or marital therapy [humanistic perspective].

Treatment techniques of depressive and bipolar disorders and suicide

Bipolar

Two pole.

Melancholia

Very severe cases of depression.

• Past and present mood symptoms. • Risk factors such as interpersonal and cognitive factors. • Medical and treatment history. • Ongoing problems and comorbid diagnoses. • Motivation for change. • Social support. • Suicidal thoughts and behaviors (see Assessment of Suicide section).

What are important topics to cover during an interview for depression?

1. beneficence 2. nonmaleficence 3. autonomy 4. justice

What are the several ethical principles for therapist to consider ECT according to Max Fink?

At every intake, but especially if someone has suicidal behavior, suicidal ideation, or has attempted suicide.

What is it important to assess suicidal thoughts/risk?