Mood Disorders The structure of mood disorders

1. Unipolar disorder refers to the experience

The experience of depression or mania, either of either depression or mania, and most
alone or in combination, is a feature of all mood individuals with this condition suffer from
disorders. unipolar depression. Bipolar disorder refers to
alternations between depression and mania.
DSM-IV-TR criteria for a major depressive 2. Feeling depression and mania at the same
episode include: time is referred to as a dysphoric manic or mixed
episode. In these episodes, patients usually feel as
a. Extremely depressed mood state lasting at least if their mania is out of control, and become
2 weeks. anxious or depressed regarding this experience. A
b. Cognitive symptoms (e.g., feeling worthless, recent study indicated that 30% of patients
indecisiveness). hospitalised for acute mania actually had mixed
c. Disturbed physical functions (e.g., altered sleep episodes.
patterns, changes in appetite/weight, loss of 3. Almost all major depressive episodes remit
energy) often referred to as somatic or vegetative without treatment. Manic episodes remit without
symptoms. Such symptoms are central to this treatment after about six months. It is important to
disorder. determine the course or temporal pattern of the
d. Anhedonia, or the loss of interest or pleasure in depressive and manic episodes. Different patterns
usual activities. appear in the DSM-IV-TR under the heading
‘course modifiers for mood disorders.
Average duration of an untreated major depressive
episode is 4 to 9 months. Course modifiers characterise the past mood state
and are helpful to predict the future course of the
Mania refers to abnormally exaggerated elation, disorder. Understanding the course is related to
joy, or euphoria. Such episodes are accompanied predicting future occurrences of mood changes
by extraordinary activity (i.e., hyperactivity), and in helping to prevent them.
require decreased need for sleep, and may include
grandiose plans (i.e., believing that one can Depressive disorder
accomplish anything). Speech is typically rapid 1. Major depressive disorder, single
and may become incoherent, and may involve a episode is defined, in part, by the absence of
‘flight of ideas’ (i.e., attempt to express many manic or hypomanic episodes before or during the
ideas at once). episode. The occurrence of one isolated
depressive episode in a lifetime is rare, and
A hypomanic (hypo means below) episode is a unipolar depression is almost always a chronic
less severe version of a manic episode that does condition that waxes and wanes over time, but
not cause marked impairment in social or seldom disappears.
occupational functioning.
2. Major depressive disorder, recurrent
DSM-IV-TR criteria for a manic episode include: requires that two or more major depressive
episodes occur and are separated by a period of at
a. A duration of 1 week; less if the episode is least 2 months during which the individual is not
severe enough to require hospitalisation. depressed. About 85% of single-episode cases
b. Irritability often accompanies the manic episode later have a second episode of major depression.
toward the end of its duration.
c. Anxiousness and depression are often part of a The median lifetime number of major depressive
manic episode. episodes is four, and the median duration is 4 to 5
d. Inflated self-esteem or grandiosity. months.

Average duration of an untreated manic episode is 3. Dysthymic disorder shares many of the
3-6 months. symptoms of major depression, but unlike major
depression, the symptoms in dysthymia tend to be
milder and remain relatively unchanged over long
periods of time, typically as much as 20 or 30
years. Dysthymic disorder is defined by

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persistently depressed mood that continues for at The mean age of onset for dysthymia is typically
least 2 years. During this time, the person cannot in the early 20s (i.e., late onset). The onset of
be symptom-free for more than 2 months at a dysthymia before age 21 (i.e., early onset) is
time. associated with (a) greater chronicity, (b)
relatively poor prognosis (i.e., response to
The earlier it starts, the poorer the prognosis. treatment), and (c) stronger likelihood of the
disorder running in the family. The median
One 10-year study indicated that 22% of those duration of dysthymic disorder is approximately 5
suffering from dysthymia eventually experienced years in adults and 4 years in children.
a major depressive episode.
Patients suffering from dysthymia have a higher
4. Double depression refers to both major likelihood of attempting suicide than those
depressive episodes and dysthymic disorder. suffering from major depressive disorder.
Dysthymic disorder often develops first, and this
condition is associated with severe Double depression is common, with as many as
psychopathology and problematic future course. 79% of people with dysthymia reporting a major
Indeed, many do not recover after two years, and depressive episode at some point in their lives.
relapse rates are very high.
The frequency of severe depression following the
The risk for developing depression is low until the death of a loved one is quite high, at around 62%.
early teens, when it begins to rise; the mean age Most mental health professionals do not consider
of onset is 30. There is some evidence that the depression associated with death or loss a disorder
risk of developing depression while younger is on unless very severe symptoms appear (e.g.,
the increase (although this may be due to better psychotic features, suicidal ideation, or the less-
recognition of depression in younger people). alarming symptoms that last longer than 2
months). Grief is usually resolved within several
Untreated depression does tend to remit, but months post loss, but may be exacerbated at
residual symptoms may leave the individual significant anniversaries, such as the birthday of
vulnerable to later episodes. The phenomenon has the loved one or during holidays.
been called 'kindling', as described by Kenneth
Kendler and his colleagues, for example. They a. If grief lasts longer than 1 year or so, the
found that although a first episode of depression is chance of recovering from severe grief is greatly
usually caused by a severe adversity, the reduced and mental health professionals may
experience of one depressive episode makes a become concerned.
second more likely, the second makes a third yet b. A history of major depressive episodes
more likely, and so on. may predict the development of a pathological
grief reaction or impacted grief reaction, which
Scott Monroe and Kate Harkness (2005) have include symptoms of intrusive memories and
distinguished two ways in which kindling might strong yearnings for the loved one, and avoiding
work. One is that the depressive disposition might people and places associated with the loved one.
become autonomous, so that processes that trigger Around 10-20% of bereaved individuals may
depression come to be internal rather than experience this reaction, which is associated with
external. suicidal thoughts, despite not having been
depressed previously. Some theorists suggest that
The alternative is that kindling is a sensitisation pathological grief be considered diagnostically
process in which, with increasing experience of distinct from major depression.
depression, progressively less severe adversities c. Treatment of pathological grief involving
trigger each succeeding episode. These two finding meaning in the loss, incorporating positive
explanations have not yet been distinguished by emotions into the grief and finding ways to cope
research. show better outcomes than interpersonal therapy.

One implication seems to be that more effort

should be made to clear up residual symptoms of Bipolar disorders
depression and not just accept a reduction in 1. The core, identifying feature of bipolar
symptoms. disorders is the tendency of manic episodes to

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alternate with major depressive episodes. Beyond One of the reasons why this is a problem is
that, bipolar disorders parallel depressive because the mood stabilising drugs given to
disorders (e.g., a manic episode can occur once or Bipolar patients have significant side effects.
repeatedly). Another problem is that they are not receiving the
treatment they do need. The lead author thinks
2. Bipolar I disorder is the alternation of that people are diagnosing conditions that they
full manic episodes and depressive episodes. know how to treat.
a. Average age of onset is 18 years, but it can
begin in childhood. 6. Cyclothymic disorder is a more chronic
b. Tends to be chronic. version of bipolar disorder where manic and major
c. Suicide attempts are estimated to occur in depressive episodes are less severe. Such people
17% of patients, usually in a depressive episode. tend to remain in either a manic or depressive
mood state for several years with very few periods
A study reported in 2010 by Solomon and of neutral (or euthymic) mood. For the diagnosis,
colleagues found that that, for patients with the pattern must last for at least 2 years (1 year for
Bipolar I disorder, the median duration for any children and adolescents). Such people are also at
type of mood episode - either mania or depression increased risk for developing bipolar I or II
- was 13 weeks. disorder.
a. Average age of onset is about 12 or 14 years.
b. Cyclothymia tends to be chronic and lifelong.
3. In bipolar II disorder, major depressive c. Most are female.
episodes alternate with hypomanic episodes.
a. Average age of onset is 19-22 years, but it Additional defining criteria for mood
can begin in childhood. disorders or subtypes of depression
b. Only 10 to 13% of cases progress to full Symptom specifiers can be helpful in determining
bipolar I disorder. the most effective treatment and are of two broad
c. Tends to be chronic. types: those that describe the most recent episode
d. Suicide attempt rates are estimated at 24%. of the disorder, and those that describe its time
course or temporal pattern.
4. Although major depression and bipolar disorder
were once thought to be distinct conditions, some Those related to the most recent episode are:
studies have indicated that about 25% of  Atypical (Oversleep, overeat, gain weight,
depressed individuals may go on to experience a anxious)
full manic episode, with over two-thirds of  Melancholic (severe, anhedonia and
depressed individuals endorsing some manic possible weight loss)
symptoms. Thus, these conditions may be best
 Chronic (major depression lasting at least
described as existing on a continuum.
2 years)
 Catatonic (absence of movement – very
5. Completed suicide in bipolar disorder is 4
serious) (with mania, the movements are
times more common than in recurrent major
bizarre or purposeless)
depression. Long-term studies show completed
suicide rates of 8-11% in bipolar disorder.  Psychotic (Mood congruent/ incongruent)
 Postpartum (may experience manic or
A recent study (Zimmerman, Ruggero, depressive episodes)
Chelminski, & Young, 2009) suggests that there Examples of the subtypes related to the time
are problems with the Diagnosis of Bipolar course are:
Disorder. An earlier study found that 57% of those  Full recovery versus left with residual
diagnosed with bipolar disorder had been symptoms
misdiagnosed. The Zimmerman study looked at  Rapid cycling
what disorders they actually had, using the SCID  Seasonal Affective Disorder (SAD)
structured interview. They found that nearly half
had major depression, while borderline personality SAD is usually associated with lower levels of
disorder, post-traumatic stress disorder (PTSD), sunlight in the extreme latitudes.
generalised anxiety and social phobia occurred in
roughly one-quarter to one-third.

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Some behaviour observed during Australia’s Top compared to males. The imbalance between males
End ‘build up’ is acknowledged by some to be a and females is accounted for largely by major
form of SAD (sometimes known in this area as depressive disorder and dysthymia.
‘Mango Madness’ or ‘Going Troppo’).
Bipolar disorders, apart from cyclothymia, are
Postpartum Depression distributed equally between males and females.
Prevalence is between about 1 and 10% of births.
A paper published in 2010 by Julia Sacher and B. Estimates of the prevalence of mood disorders
colleagues of Leipzig have located a plausible in children and adolescents vary widely. The
biological trigger for this. It has been known for consensus is that depressive disorder occurs less
some time that there is a rapid fall in the level of often in children than adults but that this
oestrogen after birth. Sacher’s team found that this difference closes somewhat during adolescence,
coincided with an increase in monoamine oxidase where depression becomes more frequent
A (MOA) in the brain. This enzyme breaks down compared to adults. Children less than 9 years of
both serotonin and dopamine, neurotransmitters age show more irritability and emotional swings
that are associated with contentment. Low levels rather than classic manic states, and are often
of these may trigger depression. Levels of MOA mistaken as hyperactive. Bipolar disorder is rare
peak at about 5 days after birth, the time new in childhood, but rises substantially in
mothers often hit their lowest point. This study adolescence, as does suicide.
suggests that drugs that inhibit MOA may prevent
or treat postnatal depression.
C. As many as 18% to 20% of elderly nursing
home residents may experience major depressive
Variation in the appearance of episodes, which are likely to be chronic. It is
depression difficult to diagnose depression in the elderly due
to medical illnesses and symptoms of dementia.
Some researchers think that depression does not Generally, the prevalence of major depressive
have the same appearance in all groups – that the disorder in the elderly is about half that in the
classic DSM-IV signs and symptoms are mainly general population. Anxiety disorders more often
the pattern seen in adult, western women. accompany depression in the elderly. Menopause
may increase rates of depression among women
Younger children may have different signs, for who have never previously been depressed, which
example. Preschoolers may not show persistent may be due to biological factors or life changes.
symptoms, but have bouts of sadness interspersed o The gender imbalance in depression
with periods of normal behaviour. One feature of
disappears after age 65.
depression - a loss of interest in things a person
once enjoyed - appears to be the strongest sign of Co-Morbidity
major depression in young children. This is still a
controversial diagnosis though. Most people who are depressed are also anxious,
whereas not all those who are anxious are
According to William Pollack, director of the depressed.
Centers for Men and Young Men at McLean
Hospital in Boston, depressed men are more Causes of Mood Disorders
likely to behave recklessly, drink heavily or take
drugs, drive fast and/or express anger. Pollack Biological dimensions
believes that the differences in appearance lead to 1. Family studies indicate that the rate of mood
men being less likely to be diagnosed with disorders in relatives of probands (i.e., the person
depression, which may be one of the reasons they known to have the disorder) with mood disorders
are four times more likely to die by suicide than is generally two to three times greater than the rate
women. in relatives of people without the disorder. The
most frequent mood disorder in relatives of people
Prevalence of Mood Disorders suffering from mood disorders is unipolar
A. About 13-16.6% of individuals experience depression.
some type of mood disorder during their lifetimes,
with 5.2-6.7% in the past year. Females are twice 2. Twin studies reveal that if one identical twin
as likely to be diagnosed with a mood disorder presents with a mood disorder, the other twin is 3

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times more likely than a fraternal (non-identical) 6. Sleep disturbances are a hallmark of most
twin to have a mood disorder, particularly for mood disorders. Depressed people move into the
bipolar disorder. Severe mood disorders may have period of rapid eye movement sleep (REM) more
a stronger genetic contribution than less severe quickly than non-depressed people and also show
disorders. There also appear to be sex differences diminished slow wave sleep (i.e., the deepest and
in genetic vulnerability to depression, with most restful part of sleep). This REM effect is
heritability rates being higher for females reduced for people who have depression related to
compared to males. The environment appears to recent life stress. REM activity is intense in
play a larger role in causing depression in males depressed people. Depriving depressed people of
than females. sleep improves their depression. People with
bipolar disorder and their children show increased
Twin studies also support the contention that sensitivity to light (i.e., greater suppression of
unipolar and bipolar disorder are inherited melatonin when exposed to light at night). A
separately. Studies now indicate the contribution relationship between seasonal affective disorder,
of a small group of genes that explain heritability sleep disturbance, and disturbance in biological
of some types of depression. rhythms has thus been proposed.

3. Data from family and twin studies also suggest Brain wave activity
that the biological vulnerability for mood Different alpha electroencephalogram (EEG)
disorders may reflect a more general vulnerability values have been reported in the two hemispheres
for anxiety disorders as well. of brains of depressed people. Depressed people
show greater right-side anterior activation of the
4. Many reports implicate neurotransmitter cerebral hemispheres (i.e., less left-side activation
systems in the aetiology of depression. Research and less alpha wave activity) than non-depressed
implicates low levels of serotonin as a factor in people. This type of brain function may be an
mood disorders but only in relation to other indicator of a biological vulnerability for
neurotransmitters, including norepinephrine and depression, as it is seen in adolescent offspring of
dopamine. One of the functions of serotonin is to depressed mothers.
regulate systems involving norepinephrine and
dopamine. The permissive hypothesis says that
when serotonin levels are low, other Psychological dimensions
neurotransmitters are permitted to range more 1. Stressful and traumatic events
widely, become dysregulated, and contribute to influence mood disorders, although the
mood irregularities. context, meaning, and memory of an
event must be considered. A
Dopamine is more involved in mania. relationship has been found between
severe life events, onset of depression,
5. Another theory of depression has implicated the poorer response to treatment, and
endocrine system, particularly elevated levels of longer time before remission.
cortisol. Cortisol and other neurohormones are a
key focus of study in psychopathology. This area Some studies have found that jetlag can trigger a
of research has led to the controversial bipolar episode.
dexamethasone suppression test (DST).
Dexamethasone is a glucocorticoid that suppresses New research suggests that one-third of the
cortisol secretion. As many as 50% of those with association between stressful life events and
depression, when given dexamethasone, show less depression is due to a vulnerability whereby
suppression of cortisol. However, people with depressed people place themselves in high-risk
anxiety disorders also demonstrate no suppression. stressful situations (i.e., reciprocal gene-
environment model). In addition, stressful life
New research findings indicate that elevated levels events and circadian rhythm disturbances may
of stress hormones in the long term may interfere trigger manic episodes. However, only a minority
with the production of new neurons (i.e., of people experiencing a negative life event
neurogenesis), especially in the hippocampus, develop a mood disorder; therefore, interaction
which may result in disrupted memory processes. with a biological vulnerability is likely.

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2. According to Martin Seligman’s learned Social and cultural dimensions
helplessness theory of depression, people develop
1. Marital dissatisfaction and depression are
depression and anxiety when they assume they
strongly related, and marital disruption often
have no control over life stress. A depressive
precedes depression. This seems particularly true
attributional style has the following three
for men. In addition, high marital conflict and/or
characteristics:
low marital support are important in the aetiology
a. First, the attribution is internal in that the
and recurrence of depression. Conversely,
person believes negative events are their fault.
continuing depression may lead to the
b. Second, the attribution is stable in that the
deterioration of a marital relationship.
person believes the situation will continue into the
foreseeable future.
2. Gender imbalances occur across the mood
c. Third, the attribution is global in that the person
disorders (with the exception of bipolar
believes negative events will influence many life
disorder) and this is a world-wide
activities.
phenomenon. Around 70% of people with
major depressive disorder and dysthymia are
3. Studies indicate that negative cognitive styles
women.
precede, and thereby may operate as a risk factor
for, depression.
3. The number and frequency of social
relationships and contact may be related to
4. Attributions are important as a
depression. A lack of social support appears to
vulnerability that contributes to a sense of
predict the later onset of depressive symptoms,
hopelessness; a feature that distinguishes
and high expressed emotion (patterns of
depressed from anxious individuals.
interaction characterised by criticism, blame, and
conflict) or dysfunctional families may predict
5. Aaron Beck, the founder of Cognitive Therapy,
relapse. Conversely, substantial social support is
proposed that depression results from a tendency
related to rapid recovery from depression.
to interpret life events in a negative way. People
with depression often engage in several cognitive
errors and think the worst of everything. The
An integrative theory of the aetiology of
following examples of cognitive errors are mood disorders
illustrated in the textbook: 1. Depression and anxiety may share common
a. Depressed people to emphasise the biological/genetic vulnerabilities, such as an
negative rather than positive aspects of a situation. overactive neurobiological response to stressful
b. They also have a tendency to take one life events.
negative consequence of some event and
generalise to all related aspects of the situation. 2. Psychological vulnerabilities, such as
attributions, correlate highly with biochemical
6. According to Beck, people with depression markers. Childhood adversity and exposure to
consistently make such cognitive errors, as depressed caregivers may be related to the later
represented in thinking negatively about development of mood disorders.
themselves, their immediate world, and their
future (called the depressive cognitive triad). 3. The onset of stressful life events may then
These beliefs may comprise a negative schema, or activate stress hormones that affect certain
an automatic and enduring cognitive bias about neurotransmitter systems, including turning on
aspects of life. Substantial empirical evidence certain genes. Extended stress may also affect
supports this theory, as those of you who have circadian rhythms and activate a dormant
taken PSY390 will know. psychological vulnerability characterized by
negative thinking and a sense of helplessness and
7. Current integrative models of cognitive hopelessness.
vulnerability for depression implicate both learned
helplessness and negative cognitive styles as risk 4. In addition, psychological vulnerabilities such
factors for depression. One study has as feelings of uncontrollability may be triggered.
demonstrated that negative cognitive styles do All of this is dependent, however, on mediating
confer vulnerability for later depression. environmental factors such as interpersonal
relationships.

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Treatment of mood disorders
Three main types of antidepressant medications Common side-effects of Prozac are physical
are used to treat depressive disorders: agitation, sexual dysfunction or low desire,
insomnia, and gastrointestinal upset.
1. Tricyclic antidepressants are still widely used
treatments for depression, and include imipramine Newer antidepressants, such as Venlafaxine and
(Tofranil) and amitriptyline (Elavil). It is not yet Nefazodone work on slightly different
clear how these drugs work, but initially at least mechanisms than other SSRIs, and are comparable
they block the reuptake of norepinephrine and to effectiveness of older antidepressants.
other neurotransmitters (i.e., down-regulation of
the post-synaptic receptors). This process may St. John's Wort (hypericum) is receiving
take anywhere between 2 to 8 weeks, and patients attention as an herbal solution for depression.
often feel worse and develop side-effects before Preliminary studies suggested that St. John's Wort
feeling better. Side-effects include blurred vision, works better than placebo in alleviating depression
dry mouth, constipation, difficulty urinating, and works as well as low doses of other
drowsiness, weight gain, and sexual dysfunction. antidepressant medications, although one recent
Because of the side-effects, about 40% of patients NIH study found no benefit of the drug. St. John's
stop taking the drugs. Tricyclics alleviate, but do Wort also appears to alter serotonin function and
not eliminate, depression in 50% of cases has few side-effects.
compared to 25-30% of people taking placebo.
Tricyclics may be lethal in excessive doses. A recent study indicated that there is some benefit
of switching from one medication to another in
cases of persistent depression, with some people
2. Monoamine oxidase inhibitors (MAOI) work benefiting from the change to a second drug or
by blocking an enzyme monoamine oxidase that addition of a second drug.
breaks down serotonin and norepinephrine. MAO
inhibitors are slightly more effective than Current studies indicate that these drug treatments
tricyclics and have fewer side-effects. However, are effective with adults, but not necessarily with
eating tyramine foods (e.g., cheese, red wine, children, and may cause substantial negative side-
beer) or cold medications with the drug can lead effects in children. Similar concerns are evident
to severe hypertensive episodes and occasionally for the elderly population. Overall, recovery from
death. New MAO inhibitors are more selective, depression may not be as important in treatment as
short acting, and do not interact negatively with preventing the next episode of depression from
tyramine. Use of MAO inhibitors has decreased occurring. Drug treatment is typically extended
significantly in recent years. well past the end of a patient's current depressive
episode.

3. Selective serotonin reuptake inhibitors It is important to note that approximately 30% of

(SSRIs) specifically block the pre-synaptic depressed people do not respond to these
reuptake of serotonin, thus increasing levels of medications, and females of childbearing age
serotonin at the receptor site. Fluoxetine (Prozac) must avoid conceiving while taking
is the best known SSRI, although Sertraline antidepressants.
(Zoloft) is probably prescribed most often. Risks
of suicide or acts of violence are no greater with The benefits of SSRIs often require three to four
Prozac than with any other antidepressant weeks to become apparent, so critical days pass
medication in adults. In adolescents, the data are before the success of the prescription can be
mixed regarding whether or not SSRIs are related determined.
to suicidality. It is possible that SSRIs confer an
initial risk of suicidal thoughts (in the first few Thus, the discovery of treatments with a more
weeks), but later are related to decreased rapid onset is a goal of biological psychiatry. The
suicidality. first drug found to produce rapid improvement
in mood was the NMDA glutamate receptor
The U.S. Food and Drug Administration carried antagonist, ketamine (used as an anaesthetic).
out a review of 372 trials involving nearly However, Furey and Drevets (2006) report that
100,000 people who took antidepressants. another medication, scopolamine, also appears to

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produce replicable rapid improvement in mood.
Scopolamine temporarily blocks the muscarinic Electroconvulsive therapy (ECT) is the
cholinergic receptor, thought to be overactive in treatment of choice for very severe, unresponsive
people suffering from depression. depression. The patient is anesthetised and is
given muscle-relaxing drugs to prevent bone
In a DB RC study, Scopolamine was found to breaks from convulsions during seizures and is
reduce symptoms of depression within three days then given a brief (less than 1 second) electric
of the first administration. Half of participants shock to the brain. The result is convulsions
experienced full symptom remission by the end of lasting for several minutes. Treatments are usually
the treatment period and the antidepressant effect administered once every other day for a total of 6
persisted for at least two weeks without further to 10 treatments.
treatment.
Side-effects are few and are limited to short-term
The efficacy of scopolamine is interesting because memory loss and confusion, both of which usually
the blocking of muscarinic receptors was a disappear after a week or two. Approximately
property of tricyclic medications. With these 50% of people not responding to medication
medications, the muscarinic receptor blockade benefit from ECT. However, relapse is extremely
was mostly viewed as the cause of unwanted side common, necessitating follow-up with
effects, such as constipation, sedation, and antidepressant drugs. The mechanism of action for
memory impairments. ECT is unclear.

Newer antidepressants, such as SSRIs or SNRIs, Transcranial magnetic stimulation (TMS) is a

were explicitly designed to avoid blocking new procedure that is related to ECT, but involves
muscarinic receptors. Yet, these data raise the setting up a strong magnetic field around the
possibility that this strategy may have increased brain. Mixed data exist regarding whether TMS is
the tolerability of these medications at the expense superior to ECT.
of providing effective and timely relief.
Some non-drug biological approaches are also in
Lithium is a common salt found in the natural development, such as implanting a transmitter that
environment, including drinking water. Lithium stimulates the vagus nerve, thought to influence
has historically been the primary drug of choice in neurotransmitter production. Deep brain
the treatment of bipolar disorder. Side-effects may stimulation via electrodes in the limbic system is
be severe, and dosage must be carefully regulated also a possible approach. Both of these treatments
to prevent toxicity (poisoning) and lowered are for treatment-resistant depression.
thyroid functioning. Substantial weight gain is
also a common side-effect. Debate exists as to At least three major psychosocial treatments are
how lithium works, but possibilities include the available for depressive disorders.
reduction of dopamine and norepinephrine or
changes in neurohormones. About 30-60% of 1.Aaron Beck's cognitive therapy involves
people with bipolar disorder respond well to teaching clients to examine the types of thinking
lithium treatment. processes they engage in while depressed and
recognize cognitive errors when they occur.
In other cases of bipolar disorder, anti-seizure Clients are informed about how these processes
medication may be effective. Valproate, an lead to depression and faulty thinking patterns are
anticonvulsant has recently overtaken lithium as modified. Clients also monitor and record their
the most frequently prescribed mood stabiliser, thoughts between therapy sessions and are
and is equally effective in reducing mood cycling, assigned homework to change their behaviour.
though it does not prevent suicide as well as Increased behavioural activity to elicit social
lithium. reinforcement and to test hypotheses about the
world is also used. Treatment usually takes 10 to
Regardless of the actual drug used for treatment of 20 sessions.
bipolar disorder, many patients are noncompliant
or discontinue their medications, possibly because 2. Lewinson and Rehm developed a form of
of the “high” many experience during manic cognitive-behaviour therapy for depression that
states. focused initially on reactivating depressed patients

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and countering their mood by bringing them in schedules while also improving relationships.
contact with reinforcing events. More recent IPSRT has shown a benefit in reducing the
approaches have also stressed the avoidance of frequency of manic and depressive episodes.
social and environmental cues that produce Family therapy may also be beneficial for bipolar
negative affect or depression. disorder.

It is possible that increased activities alone may A critical viewpoint on antidepressant

improve self-concept and lift depression, medication
suggesting that the behavioural component of Twenty years ago people thought of depression as
CBT may be the active ingredient of treatment. an emotion related to feeling sad. To treat it, you
had to find out why that person felt sad. Since
3. Interpersonal therapy (IPT) focuses on then, drug companies have been influential in
resolving problems in existing relationships and/or convincing people that depression is a medical
building skills to develop new relationships. Like disease and should be treated by drugs.
CBT approaches, IPT is highly structured and
seldom takes longer than 15 to 20 weekly If a person is very unhappy, and it goes on for
sessions. The therapist and client identify life months, that probably means there's something
stressors that precipitate depression, and then seriously wrong in that person's life. It's not for
address interpersonal role disputes, adjustments to trivial reasons. It is probably not going to be easy
losing a relationship, acquisition of new to change that.
relationships, and social skills deficits.
Some drugs will provide symptomatic relief and
Recent studies comparing the results of cognitive there are times when symptomatic relief can be
therapy and IPT to those of tricyclic important. So there should be a respectable, but
antidepressants and other control conditions for small place for the use of drugs in treating
major depressive disorder and dysthymia have emotional disorders.
shown that psychosocial approaches and
medication are equally effective, and that all The problem is that sometimes psychiatrists
treatments are better than placebo and brief prescribe a psychiatric medication for
psychodynamic therapy. symptomatic relief and then lose sight of that fact
that they are just relieving symptoms and think
Current data suggest that combining medication they are providing a cure, and the drugs can't do
and psychosocial treatments may provide an that. That scenario has been re-enacted several
added benefit over providing each treatment times in the history of psychiatry.
alone. However, combining two treatments is
expensive so a psychosocial treatment may be For about 10 years there has been research
tried first before adding other options. showing that antidepressants don't reduce the
frequency of suicide. For some individuals the
Psychosocial interventions (i.e., cognitive therapy drug actually increases the suicide rate. Peter
and IPT) seem helpful in preventing relapse. In a Breggin [the author of the 1990s bestseller
recent study, cognitive therapy showed an Talking Back to Prozac] says that in some cases
enduring effect over medication in preventing people are very despondent, and then they are
later recurrence of depression. given a drug that artificially makes them more
energetic - that's not a good combination.
Though medication is the preferred treatment for
bipolar disorder, most clinicians emphasise the I think that the main thing that prevents people
need for psychosocial interventions to manage from suicide is not a drug - it is having a
interpersonal and practical problems, particularly relationship with someone who really cares about
non-compliance with medication and family them.
stress. These have been shown to be related to
increased risk of relapse. Having said all that, I am aware of one survey
carried out in the USA in 2010 by Consumer
A relatively new approach called interpersonal Reports magazine that said that 80% of the
and social rhythm therapy (IPSRT) focuses on respondents preferred to take a pill than a talking
helping patients to regulate their sleep cycles and therapy.

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Suicide  Interviews with parasuicides and high-risk
According to the WHO, every 40 seconds groups
someone in the world dies by suicide. Every 3  Randomized controlled trials
seconds someone attempts it. On a worldwide
basis, more people die from suicide than wars or Risk factors in suicide
murders. Poor mental health has long been recognised as an
important factor in suicide. Suicides and
Definitions parasuicides share clinical characteristics that are
Suicide involves the intentional taking of one's different from others:
life. The difficulty lies in determining this intent.  Depression - About 15% of depressed
Those contemplating suicide often aren't clear people will eventually take their own lives
about their own intention. and about two thirds of all suicides have a
depressive illness (Maris, 1991). This is
Parasuicide refers to any non-accidental act of higher than the figure given by Barlow and
self-injury that does not result in death. This Durand (2008), which suggests a figure of
definition has the benefit that we do not have to up to 11%.
make assumptions about intention, which we do if  Family history
we use the phrase ‘attempted suicide’.  Low serotonin levels
 Alcoholism - long term, rather than short
Being single, widowed, divorced or separated term, alcoholism is a risk factor
increases the risk of suicide compared to being  Substance abuse
married.  Anti-social behaviour
 Body dysmorphic disorder (BDD)
Suicide is more common amongst manual and substantially raises the risk
semi-skilled labourers than among other  Suicide risk is higher among those
occupational groups. However, some occupational diagnosed with anorexia nervosa.
groups in western nations are more vulnerable,  Schizophrenia - about 10% of
including veterinarians, dentists and farmers. schizophrenics die by suicide.
Having satisfying, productive work is associated  Personality disorder, particularly
with reduced risk and work-related problems are Borderline PD, raises the risk.
associated with increased risk.  Suicidal ideation
 High stress and PTSD
How do people commit suicide?
 Child abuse of all types - both abusers and
Men generally use more violent methods than the abused are at higher risk
women. In many parts of Europe, men choose  A history of self-harm or a previous
hanging and women choose poisoning. In the suicide attempt
USA, men choose handguns and women again
 Media coverage (sensationalising and
choose poisoning. In Fiji and other parts of the
describes the method)
Pacific Region, Paraquat (weed killer) and
hanging are very common for both males and
As many as 25% of adolescent suicides in Europe
females. The methods used reflect the availability
have a history of alcohol abuse. Substance abuse
of options. Some people have preferred
is a significant risk factor for this group.
methods of killing themselves and if access to
that is restricted, they are less likely to kill
For parasuicides, people with three or fewer of
themselves.
the factors in the following list had a 5% chance
of repeating an attempt, while those with eight or
How do psychologists study suicide?
more had a 41.5% chance:
The main methods are:  Previous parasuicide
 Analysis of official suicide statistics  Personality disorder
 Inquest papers and records  High alcohol consumption
 Longitudinal cohort analysis  History of psychiatric treatment
 Suicide note analysis  Unemployment
 Psychological autopsy  Unskilled labourer
 Drug abuse

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  Criminal record an increase in the frequency of negative life events
 Violence (in the previous 5 years) as in the month before a suicide attempt.
victim or perpetrator Bereavement, divorce, separation and conflict are
 Aged between 25 and 54 amongst the most frequently seen events. Also,
 Single, widowed or divorced suicide attempters have poorer social skills and
poorer peer relationships than others.

Social Factors in Suicide

Personal Factors in Suicide
People who are isolated socially are more likely
to kill themselves than those who are not. In the biomedical model, suicide is caused by
Inadequate social support is implicated in many biological factors. For example, neurotransmitter
psychological problems, as well as increased imbalances cause mental illness, which in turn
suicide risk. causes suicide. However, people may have a
neurotransmitter imbalance and not attempt
People in rural areas are at greater risk than those suicide.
in urban areas. In a study of rural suicides in
Japan, Watanabe, Hasegawa & Yoshinaga (1995) In the biopsychosocial model, suicide is seen as
found that the modern shift from extended to the result of the interaction of biological,
nuclear families and the dissolution of traditional psychological and social factors. A personal factor
family structures led to feelings of isolation and such as impulsivity can interact with other
abandonment among older people. predisposing factors to make a suicide attempt
more likely.
In times of civil unrest, suicide rates may be
lower, as in the 'Troubles' in Northern Ireland. It is In many cases, suicide should be seen not as an
thought that the unrest led to a greater feeling of attempt to end their life, but as an attempt to
community and solidarity, which buffered against end an unbearable psychological pain in
suicide. The suicide rate rose as the unrest someone who cannot see any other way of
diminished, but has subsequently declined. achieving that.

Prisoners have many of the risk factors for Aaron Beck, developer of Cognitive Therapy
suicide and the likelihood of suicide or (1974), saw feelings of hopelessness as the
parasuicide is greatest shortly after admission in mediator between depression and suicidal
most countries. behaviour.

Among females, higher suicide rates are Parasuicide patients take longer to recall positive
associated with lower levels of religious belief. memories about their lives. They also recall more
This is not seen among men. general memories about their lives, finding it too
painful to recall specific memories.
I mentioned that people with satisfying,
productive jobs are less likely to die by suicide. Perfectionism, the setting of unrealistically high
Unemployment is connected with increased goals, is another predictor of suicidal behaviour.
suicide and parasuicide. Perfectionists are overly concerned with the most
minor of mistakes. They also doubt their own
One study reported that people suffering ability and tend to perceive a task as a failure if it
depression, physical illness or unemployment, includes a hint of a mistake. This may be linked to
who receive social support, experienced more parental rearing style, where parental love was
suicidal ideation (Brown & Vinokur, 2003). The conditional on performance. Perfectionists are
critical factor seems to be the inability to driven by the fear of failure rather than the desire
reciprocate the support they receive. This leads for success.
them to feeling a burden - a very significant risk
factor. Those who consider themselves a burden to
others are more likely to complete their suicide
A study of 50 parasuicides found that they had attempt and to use more lethal means in the
experienced twice as many major life events as process, according to Thomas Joiner of Florida
comparable non-parasuicides. Other studies found

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State University in Tallahassee in a 2002 issue of  Recent events
the Journal of Social and Clinical Psychology.  Ideation
 Creating a plan
The investigators found that suicide completers  The plan includes a means
thought of themselves as more of a burden to  Access to the means
others than did the attempters. The notes left by  They have made preparations not to be
suicide completers more highly endorsed the idea discovered.
that their loved ones would be better off after they
were gone. Some treatment options that have evidence of
effectiveness:
Suicide myths
 No-suicide contract
“People who talk about suicide will not kill  Hospitalisation
themselves.” Up to 90% of suicides give some o Complete or partial
kind of prior warning.  Problem Solving Therapy works on the
premise that suicide and parasuicide
Conversely, some people believe that talking involve a problem-solving failure of some
about suicide to someone contemplating it will kind
make it more likely that they will make an
 Manual-assisted Cognitive-Behaviour
attempt. This is also not supported by studies.
Therapy (MACT), which involves the
patient receiving manuals as well as
A model of suicide
sessions of CBT
These findings lend themselves to a heuristic
model for suicide. This model proposes that, in
order to attempt suicide, an underlying condition, Suicide Prevention
such as a mood disorder, anxiety disorder,
Reducing the access to lethal means can reduce
perfectionism, substance abuse, and/or impulsivity
suicide deaths. Although some people may choose
is likely to be present.
alternate means, there is evidence that some
people have a preferred method and if that is not
The suicide act itself will usually be preceded by a
available, they do not attempt suicide. Or the
stressful event that may be a result of the
alternative may be less lethal, thus increasing the
underlying condition. Psychological autopsy
likelihood of interception.
studies suggest that the stress commonly leads to
extreme anxiety or distress.
In some countries, paracetamol is only sold in
packets of 16 tablets or less, without a
Inhibitory and facilitating factors come into play
prescription. First time parasuicides often do not
after the precipitating event and the balance
know the deadly dose (20 tablets with a large
between them will determine whether the outcome
quantity of alcohol can kill) and so may take a
is an attempt at suicide or not. Inhibiting factors
non-lethal dose.
that make suicide less likely include living in a
culture in which suicide is strongly taboo, having
The Early Psychosis Prevention and
available support or the presence of others, and
Intervention Centre in Melbourne, reports
having a slowed-down mental state. Conversely,
success in reducing the incidence of suicide
the presence of other factors may facilitate
among young people diagnosed with a psychotic
suicide. These include living in a culture in which
disorder. The principles of the centre can be
taboos about suicide are weak, having ready
applied to preventing all types of suicide:
access to weapons or other methods of suicide,
learning of a recent example of suicide by hearsay
 To enhance the early detection of
or in the media, being in an agitated or excited
psychosis
state, and being alone.
 To improve mechanisms for access to
Treatment psychiatric services
 To develop 'user-friendly' non-stigmatising
First it is important to assess where the person is
mental health services for young people
in terms of:
 To develop adequate support for the carers
 Previous attempts
of individuals with psychosis

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  To develop more effective treatments for useful in providing support for people, in addition
those with, or at risk of, developing early to telephone help lines. However, this is one of the
psychosis more expensive options.
 To develop suicide prevention structures
within health services Care needs to be taken in how the media portrays
suicide. Portrayals glamorising the suicide of Kurt
The non-stigmatising element is particularly Cobain, singer with rock band Nirvana, may have
important for young men. Many men are taught led to the increase in suicides by young people
from an early age not to show weakness, to be shortly after, although that did not happen in
independent and not to seek help for problems – Seattle, Cobain’s home town, as the press there
this is not a good combination in a young man followed the guidelines on responsible coverage
with suicidal thoughts. of suicide. Portrayals of suicides in two major
British television series, Eastenders and Casualty,
O'Connor and Sheehy (2000) propose five general were also followed by increases in suicide. In the
education and prevention strategies aimed at high- case of the latter, by 17% in the week following
risk individuals, healthcare professionals and the and by 9% in the second week. Also, the method
general public: portrayed was paracetamol and the increase in
paracetamol poisoning was greater than other
1. Promoting the importance of forms of self-poisoning.
communication. Men in particular should be
encouraged to communicate their worries and Educating GPs, counsellors and psychologists
anxieties. to better recognise patients at risk of suicide
2. The coping strategies of suicidal would help, as would alerting them to the known
individuals must be dysfunctional in some way if risk factors.
they perceive suicide as the only option. Research
into the different coping strategies of suicidal and One of the more promising approaches for men,
non-suicidal individuals should identify important and young men in particular, is to access support
differences, which can then become part of via the Internet. They could access the already
educational packages. More effective strategies, existing support groups, if they knew about them.
such as seeking social support and religious
coping should be considered.
3. Difficulties in coping with stressful
situations are not a sign of personal weakness. It is
necessary to change the general perceptions of
stressors and people's perceptions of their own
situations. Communication with significant others
and healthcare professionals is beneficial. Our
perceptions of stressful life events are crucial to
the prediction of suicide.
4. The prevalence of depression needs to be
highlighted and mood disorders destigmatised.
Knowledge of the suicidal risk factors needs to be
spread more widely.
5. Awareness of the existing services for
counselling and helping people cope with mood
disorders also needs spreading. Counselling
services should be used more often in conjunction
with GP consultations. Setting up specialist
telephone help lines and encouraging people to
use them would also be useful.

Other strategies that have proved useful elsewhere

include company training programmes aimed at
stress management and communication skills.
USA-style Suicide Prevention Centres may be

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