5/4/17
Depressive Disorders, Bipolar
Disorders, and Suicide
You look blue. Are you depressed?
Tiffany Daniels, M.S.
Depressive Disorders
•  The most common feature of all of the
Depressive Disorders is the presence of sad,
empty, or irritable mood, accompanied by
somatic and cognitive changes that significantly
affect the individual’s capacity to function.
•  What differs among them are issues of
duration, timing, or presumed etiology.
Disruptive Mood Dysregulation
Disorder
•  This disorder is new to the DSM and was
created to try and reduce the rate in which
children were being inaccurately diagnosed
with Bipolar Disorder.
•  Since new, prevalence unknown (est. 2-5%?)
•  Symptoms need to be inconsistent with
developmental level…diagnosis not to be given
to children with a developmental age < 6.
Depressive Disorders
Disruptive Mood Dysregulation
Disorder
•  The core feature of DMDD is chronic, severe
persistent irritability, mainly in children
•  This severe irritability has two prominent clinical
manifestations, the first of which is frequent
temper outbursts
•  The second consists of chronic persistently
irritable or angry mood present BETWEEN the
severe temper outbursts.
Disruptive Mood Dysregulation
Disorder
•  Predominantly male
•  Difference in prevalence between males and
females helps differentiate DMDD from Bipolar
Disorder in children, where prevalence is equal.
•  While Bipolar disorders are episodic conditions
(having periods where the children return to
their normal selves), DMDD is not.
•  DMDD highly comorbid with Oppositional
Defiant Disorder
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Major Depressive Disorder
Major Depressive Episode
•  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 (in children/
adolescents, can be irritable mood).
•  2) Markedly diminished interest or pleasure
in all, or almost all, activities most of the day,
nearly every day (includes low libido)
Major Depressive Episode
•  6) Fatigue/loss of energy
•  7) Feelings of worthlessness or excessive/
inappropriate guilt
•  8) Diminished ability to think or concentrate, or
indecisiveness
•  9) Recurrent thoughts of death (not just fear of
dying) up to and including suicidal ideation
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Major Depressive Disorder
•  To receive this diagnosis, must meet the criteria
for a major depressive episode.
•  Major Depressive episode
Five (or more) of the following nine symptoms
have been present during the same 2-week
period and represent a change from previous
functioning. At least one of the symptoms
MUST be either symptom #1 or #2.
Major Depressive Episode
•  3) Appetite changes (increase or decrease) or
significant (changes of more than 5% of body
weight in a month) weight loss or weight gain
•  4) Insomnia or Hypersomnia
•  5) Psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being
slowed down)
Major Depressive Disorder
•  Symptoms cause distress and/or impairment in
social/occupational functioning
•  Not attributable to effects of a substance or a
general medical condition (GMC)
•  Not better explained by other mental disorders
that include such features
•  There has never been a manic episode or
hypomanic episode.
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MDD vs. Grief
•  In grief, the predominant affect is feelings of
emptiness or loss, while in MDD it is persistent
depressed mood and the inability to anticipate
happiness or pleasure.
•  Dysphoria in grief is likely to decrease in
intensity over days and weeks and occurs in
waves, whereas depressed mood in MDD is
more persistent.
•  The pain of grief may be accompanied by
positive emotions and humor uncharacteristic of
pervasive unhappiness of MDD.
Major Depressive Disorder
•  For an episode to be considered recurrent,
there must be an interval of at least two
consecutive months between episodes in which
criteria for an Major Depressive Episode are not
met.
•  There are multiple symptom variation specifiers
with MDD, the two most notable of which are
With Peripartum Onset (aka Postpartum
Depression) and With Seasonal Pattern (aka
Seasonal Affective Disorder).
Prevalence and Course
•  Prevalence in 18-29 year olds 3x higher than in
those 60+
•  Might just be underreporting.
•  Reasons for underreporting in the elderly:
•  1) the society they grew up in was less
accepting of depression.
•  2) older people more sick, and depressive
symptoms can be confused with medical
problems they might also have.
•  3) cognitive impairments also muddle up the
ability to distinguish what from what.
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MDD vs. Grief
•  In grief, self-esteem is generally preserved,
whereas in MDD feelings of worthlessness and
self-loathing are common.
•  If self-derogatory ideation is present in grief, it
typically involves perceived failings of the
deceased (e.g., no closure, not telling them you
loved them enough, preventing their death).
•  If a bereaved individual thinks about death or
dying, thoughts tend to focus on joining the
deceased, whereas in MDD thoughts are
focused on ending one s life.
Prevalence and Course
•  Depression is one of the most common
psychological problems.
•  16 percent of Americans experience an episode
of major depression at some point in their lives.
•  Does this seem kind of low to you?
•  That means 84 percent of Americans go
through their lives having never experienced a
significant depression.
•  That seems kind of hard to believe.
•  Number only includes those who seek help.
Prevalence and Course
•  Prevalence varies widely (up to 7-fold
differences in some) by culture.
•  Females >males
•  First degree family members of individuals with
MDD have 2-4x higher risk for MDD than that of
the general population.
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Cost of Depression Persistent Depressive Disorder

•  Depression costs employers an estimated 44
(Dysthymia)
billion per year in lost productivity alone (not
including the cost of treatment).
•  Luckily, though, once people actually undergo
treatment, they tend to recover more quickly
and their risk of relapse is reduced.

Persistent Depressive Disorder Premenstrual Dysphoric Disorder

(Dysthymia) (PMDD)
•  Depressed mood for most of the day nearly
every day, for more days than not, nearly
continuously for more than 2 years.
•  Tons of specifiers including with pure
dysthymic syndrome , with persistent major
depressive episode , with intermittent major
depressive episodes , etc…
•  Represents an amalgam of prior DSM’s
Dysthymia and Chronic MDD

Premenstrual Dysphoric Disorder Premenstrual Dysphoric Disorder

(PMDD)
•  New to the DSM-5
•  The essential features of PMDD are mood
lability, irritability, dysphoria, and anxiety that
occur repeatedly during the premenstrual
phase and remit around the onset of menses or
shortly thereafter.
•  Symptoms must have occurred in most
menstrual cycles in the past year and must
have an adverse effect on work or social
functioning.
(PMDD)
•  Multiple symptoms must be met (see text for full
criteria)
•  12-month prevalence of PMDD is estimated to
be around 1.8%
•  Multiple rating scales to objectively aid in
diagnosis (e.g., Visual Analogue Scales for
Premenstrual Mood Symptoms, Premenstrual
Tension Syndrome Rating Scale)
•  Not the same as PMS or Dsymenorrhea

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Other Depressive Disorders
•  Substance/Medication-Induced Depressive
Disorder
•  Depressive Disorder due to another General
Medical Condition (e.g., stroke [CVA])
•  Other Specified or Unspecified Depressive
Disorder
Bipolar and Related Disorders
•  Separated out from the Depressive Disorders in
the DSM-5 and placed between the chapters on
Schizophrenia Spectrum and Other Psychotic
Disorders and the Depressive Disorders in
recognition of their place as a bridge between
the two diagnostic classes in terms of
symptomatology, family history, and genetics.
Manic Episode
1.  Inflated self-esteem or grandiosity
2.  Decreased need for sleep
3.  More talkative/pressure to keep talking
4.  Flight of ideas/racing thoughts
5.  Distractibility
6.  Increase in goal-directed activity (social, work/
school, sexual) or psychomotor agitation
7.  Excessive involvement in activities with high
risk of painful consequences (e.g., excessive
spending sprees, sexual indiscretions)
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Bipolar and Related Disorders
CIA Agent Carrie Mathison from Homeland- Bipolar I Disorder
Manic Episode
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 this period, 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:
Manic Episode
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. Not attributable to the effects of a substance
or GMC (general medical condition).
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Bipolar I Disorder
•  Bipolar I Disorder characterized by instances of
full-blown mania.
•  Though Major Depressive Episodes are
common for people with Bipolar I Disorder,
only the presence of manic episodes are
required for the diagnosis to be made.
•  12-month prevalence in the U.S. for Bipolar I is
0.6%, males and females roughly equal.
Prevalence and Course of
Bipolar
•  Is more common in creative individuals like
artists, writers, composers, etc…
•  Some have suggested that great periods of
creativity can occur during manic episodes.
Hypomanic Episode
A. Similar to mania but only requires symptoms
be present for 4 days
B. The same as mania criteria.
C. Associated with an unequivocal change in
functioning uncharacteristic of the individual
when not symptomatic.
D. Mood changes observable by others.
E. The episode is NOT severe enough to cause
marked impairment in social/occupational
functioning or to necessitate hospitalization,
and no psychotic features present.
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Bipolar I Disorder
•  More than 90 % of individuals who have a
single manic episode go on to have more than
one.
•  60% of manic episodes occur immediately prior
to a major depressive episode.
•  Heavily genetic. There is a 10-fold increased
risk among adult relatives of individuals with
bipolar disorders.
•  Suicide rate 15x higher than general
population. May account for 25% of suicides.
Example: Lois
•  A friend of mine’s mother has a long-standing
history of Bipolar I Disorder. During one of her
manic episodes, she LITERALLY filled her
entire house, save for a small path from the
door to the kitchen to the bedroom, with
shopping bags full of gift purchases. During the
episode, she spent over 70,000 dollars…..at a
small, mediocre shopping mall. Can you
imagine how much stuff you d have to buy to
rack up that much debt at the mall!
Bipolar II Disorder
•  For a diagnosis of Bipolar II Disorder, one must
meet criteria for a current or past hypomanic
episode AND a current or past major
depressive episode.
•  Technically a more true bipolar then since,
unlike Bipolar I, Bipolar II REQUIRES that both
ends of the spectrum be met.
•  If a full-blown manic episode has EVER
occurred, a person gets diagnosed with Bipolar
I, not Bipolar II, even if all other episodes have
been hypomanic.
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Bipolar II Disorder
•  U.S. 12 month prevalence = 0.8%
•  5-15% of individuals with Bipolar II show rapid
cycling (4 or more hypomanic or major
depressive episodes within one year)
•  A rapid cycling pattern is associated with a
poorer prognosis.
Theories of Mood Disorders
Mood Disorders appear to have Biological,
Psychological, and Sociocultural components.
These will be discussed here briefly.
Psychological Theories
•  Behavioral theories rely on learning principles
like learned helplessness and operant
conditioning to explain how depression
develops.
•  Cognitive theories involve skewed/distorted
patterns of thinking (mostly negative) in terms
of how depressed persons view themselves/the
world.
•  Psychodynamic theories view depressed
people as unconsciously punishing themselves
because they feel abandoned.
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Cyclothymic Disorder
•  The essential feature of Cyclothymic Disorder is
a chronic, fluctuating mood disturbance
involving numerous periods of hypomanic
SYMPTOMS (but not quite enough for
hypomania diagnosis) and periods of
depressive SYMPTOMS (but not quite enough
for a Major Depression diagnosis) that are
distinct from each other and persistent (present
nearly continuously for at least 2 years).
Biological Theories
•  Genetics- genes do have a slight component,
as evidenced by identical twin studies.
•  Neurotransmitters- dysregulation of the
monoamine neurotransmitters, aka the three
sisters (dopamine, serotonin, and
norepinephrine) has been heavily implicated.
•  The prefrontal cortex, hippocampus, amygdala,
and anterior cingulate have all been implicated.
•  Hyperactivity in the hypothalamic-pituitary-
adrenal axis in the neuroendocrine system has
also been implicated.
Psychological Theories
•  Stressful Live Events – Between 20-50% of
individuals who experience severely
stressful events develop mood disorders
•  So that means between 50-80% experience
severe stress but don’t develop a disorder…
It is likely that an interaction of factors is at
work here
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Social Theories Social Theories

•  Cohort effect- people born in one historical period are
at different risk for a disorder than are people born in
•  People with lower social status in society tend
another historical period.
to show more depression.
•  Example: People born after 1970 report higher rates
of depression. This could be because depression is •  However, different cultures have different
less stigmatized now, or it could be that technology responses.
has gotten us to be more distant now with our families/ •  African Americans tend to be more prone to
each other, and intense interpersonal social support is
anxiety disorders than depressive ones.
not there as much. (note: This is a theory, not a fact.
The opposite could be argued, that technology has •  The Amish have extremely low rates of
allowed us to be more intertwined and increase our depression.
social support).

Social Theories Treatments for Mood Disorders

•  Marital/relationship dissatisfaction, lack of

social support related to development of
mood disorders
•  Gender differences in rates of depression •  There are both Biological and Therapeutic
(equal for bipolar, but 70% of individuals treatments for mood disorders.
diagnosed with depression are
•  Generally, both in combination tends to have
women….why the imbalance?)
the best outcome.

Biological Treatments Lithium

•  Drugs- TCAs, MAOIs, and SSRIs are
commonly used for depression, with SSRIs •  Many patients respond well to lithium
being by far the most common nowadays due (about 50%) but relapse is very high
to the limited side effects and other benefits (about 70%)
that they have.
•  Thoughts as to why the high rate of
•  Lithium, a mood-stabilizing drug, is commonly relapse?
used for treating manic symptoms, like those in
Bipolar disorders.

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Biological Treatments
•  ECT- definitely the most controversial of the
treatments for mood disorders, as it involves
purposely causing seizures.
•  Also controversial because it doesn’t have the
best history, previously having been used as a
punishment in inpatient psychiatric institutions.
It can also lead to memory loss and difficulties
in learning new information.
•  Is only voluntary, much safer, more controlled,
and used only under strict circumstances today.
Biological Treatments
•  Light Therapy is used for people with
Seasonal Affective Disorder to help
reset the circadian rhythms they
associate with the sun, and generally
make them feel better.
Psychological Treatments
•  Interpersonal psychotherapy – Brief
treatment approach that emphasizes
resolution of interpersonal problems and
stressors, such as role disputes in marital
conflict, forming relationships in marriage, or
a new job.
•  Since social support is key in development of
mood disorders, this therapy approach has
been shown to be effective.
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Biological Treatments
•  Vagus Nerve Stimulation (VNS) is a new
method that has great potential for treatment of
depression in people who don’t respond to
medication.
Psychological Treatments
•  Behavioral therapies are common, however,
Cognitive-Behavioral Therapy (CBT) is
arguably the most common method used for
treating depression today.
•  CBT involves identifying & altering negative
thinking styles (e.g., catastrophic thinking)
related to psychological disorders such as
depression/anxiety and replacing them with
more positive beliefs & attitudes – and
ultimately, more adaptive behavior and coping
styles
Psychological Treatments
•  Maintenance Treatment is very
important! It involves the combination
of continued psychosocial treatment,
medication, or both designed to prevent
relapse following therapy
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Mood Disorders in Pop Culture

https://
www.youtube.com/
watch?v=4P9BTOb2Y_4

https://
www.youtube.com/
watch?v=wrSI3a1aebo

https://
www.youtube.com/
watch?v=JrsjI7DrOuQ

Depression: Jon Favreau in Swingers

Bipolar 1: Claire Danes in Homeland, Bradley Cooper in Silver
Linings Playbook, and Tom Wilkinson in Michael Clayton
•  This poster, unfortunately, is a good
example of how many people feel.

Suicide Key Terms Suicide

•  Suicidal ideation – serious thoughts about •  Suicide- is defined as the purposeful taking
committing suicide of one’s own life.

•  Suicidal plans – The formulation of a specific
method of killing oneself
•  Suicidal attempts – Effort made to kill oneself
•  Actions are typically characterized as being
made out of despair, or attributed to some
underlying mental disorder which includes
depression, bipolar disorder, schizophrenia,
alcoholism and drug abuse.

Types of Suicide Suicide Rates

•  Death seeking-clearly and explicitly seek to
end their lives.
•  Death initiators-simply hastening an
inevitable death
•  Death ignorers-intended to end their lives but
do not believe that this means the end of
their existence.
•  Death darers-are ambivalent about dying,
and they take actions that greatly increase
their chances of death but that do not
guarantee they will die.

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Gender Differences
•  Men and boys are four times more likely
than women and girls to complete suicide
•  Gender difference in suicide completion rate
is true in many nations of the world, and
across all ages ranges.
•  Men tend to choose more lethal means of
suicide than women do.
•  Men may feel that its not masculine to be
ambivalent about their intent to die or to
communicate this intent to others in hopes
that they will be prevented from succeeding.
Suicide in Children & Adolescents
•  Although suicide is relatively rare in young children,
it does happen.
•  Girls are much more likely to attempt suicide, but
boys are more likely to complete suicide.
•  Males are six times more likely then females in this
age range to commit suicide.
•  Adolescents may be especially prone to use
suicide attempts as a way of getting attention and
help for problems.
•  Adolescents who attempt suicide once are at high
risk for future attempts, which might be successful.
Social Perspectives on Suicide
•  Economic Hardships
Stressful events contribute to an increased risk of
suicide. The loss of a job or economic crisis can also
affect someone to have suicidal thoughts.
§  Serious Illness
§  Serious illnesses can bring constant pain.
§  The pain and the burden of chronic illness are too much for
some
§  Loss and Abuse
§  Loss of a loved one through death, divorce, or separation
often immediately precedes suicide attempts.
§  People feel they cannot go on with the lost relationship and
wish to end their pain.
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Ethnic and Cross-Cultural Differences
•  European Americans have higher suicide
rates than all other groups (12 people per
10,000 in the population)
•  Native Americans are close behind at (11 per
100,000 people)
•  European Americans have higher rates of
completed suicide than African Americans.
•  Hispanic youth in the U.S. are more likely to
contemplate and attempt suicide than African
American youth or European American youth.
Suicide Notes
•  Only about 1 in 4 people leave a suicide note.
•  Most suicide notes often reveal only the
obvious that suicide tends to be driven by
mental anguish and sense of futility about
going on, hopelessness.
Emile Durkheim’s (1951) Theory
–  Focused not on specific events that precipitate suicide but
rather on the mindsets that certain societal conditions can
create that increase the risk for suicide.
–  Egoistic Suicide, is committed by people who feel alienated
from others, empty of social contracts, and alone in an
unsupportive world (ex: older adult who has lost touch with
friends and family)
–  Anomic suicide, is committed by people who experience severe
disorientation because of a major change in their relationships
to society (ex: the person who has lost their high-prestige job)
–  Altruistic Suicide, is committed by people who believe that
taking their own lived will benefit society in some way. (ex: the
person who kills his or her self due to having dishonored their
family)
–  Fatalistic Suicide, committed by those who feel a loss of control
over their own destiny (ex: the mass suicide of 39 Heaven s
Gate Cult members in 1997)
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Is Suicide contagious?
•  Psychologists have identified a phenomenon
described as Suicide Contagion
•  Somehow, people are catching suicide
intentions
•  Suicide is not literally contagious, however,
there is an increase in suicides following
major media publicity of a suicide
(e.g., Kurt Cobain)
Is Suicide contagious?
•  There is also higher risk of suicide if a friend
or loved one has recently attempted/
committed suicide. Why?
•  Well, it seems that people who clearly
identify with the person may see suicide as
more acceptable
•  The stress of a friend s suicide may affect
individuals who are already vulnerable due
to pre-existing psychological disorders
Drug Treatments
•  The medication most consistently shown to
reduce the risk for suicide is lithium.
•  Studies of people with major depression or
bipolar disorder found those not treated with
lithium were 13 times more likely to commit or
attempt suicide than those who had been
treated with lithium.
•  Antipsychotic medications can be used to treat
psychotic symptoms in people with psychotic
mood disorders or schizophrenia, which may
also reduce the risk for suicidality.
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Is Suicide contagious?
•  The media often romanticizes suicide, and
frequently describes in detail the methods
used in the suicide
•  Little is reported of the tragic consequences
of failed suicide attempts or how suicide is
nearly always associated with severe
psychological disorders
Treating and Preventing
Suicidal Tendencies
•  Crisis Intervention-programs are available to
help people who are highly suicidal deal in
the short term with their feelings and then
refer them for longer care to a mental-health
specialist.
•  Suicide Hot Lines- Suicide prevention
centers, which may be part of a larger
mental-health system, or stand-alone clinics,
where suicidal people can walk in and
receive immediate care.
Psychological Treatments
•  Psychodynamic therapists focus more on
exploring unexpressed anger at others,
whereas cognitive therapists focus more on
the client s hopelessness and dichotomous
thinking.
•  Dialectical Behavior Therapy (DBT) is used
to treat people with borderline personality
disorder whose mood and self-images have
a tendency to swing between extremes.
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Guns and Suicide
•  In the Unites States, the majority of suicides,
particularly those by men, involve guns.
•  Most people who commit suicide by gun do not
buy guns expressly to commit suicide.
•  They may be depressed, get drunk, and/or
retrieve family handguns and shoot
themselves.
•  Several studies show that suicide rates
decrease when cities and states enact strict
anti-gun legislation that limits people s access
to guns.
Help for Yourself
5/4/17
What to do if either you or a
friend/ loved one is suicidal
•  Many textbooks do not cover this, but this is
VERY important
•  Suicide is the 10th leading cause of death in the
United States
•  You have a moral obligation to yourself and
loved ones to educate yourself regarding suicide
•  According to the National Suicide Prevention
Hotline 1-800-273-TALK here is some helpful
information:
Help for Someone Else
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