MOOD DISORDERS AND SUICIDE
I. Understanding and Defining Mood Disorders
A. The disorders described in this chapter used to be called
Beginning with the DSM-III-R, grouped under the heading mood disorders
because they all represent gross deviations in mood.
B. The experience of depression and mania contribute, either alone or in
combination, to all mood disorders.
1. Major depressive episode is the most commonly diagnosed and
most severe form of depression (see DSM-IV diagnostic criteria for
Major Depression). (Book--case of Katie) DSM-IV primary criteria:
a. Extremely depressed mood state lasting at least 2 weeks.
b. Cognitive symptoms (e.g., feeling worthless, indecisiveness).
c. Disturbed physical functions (e.g., altered sleep patterns,
changes in appetite/weight, loss of energy), often referred to as
somatic or vegetative symptoms. Such symptoms are
central to this disorder.
d. Anhedonia, or the loss of interest or pleasure in usual
e. Average duration of an untreated major depressive episode is 9
2. Mania refers to abnormally exaggerated elation, joy, or euphoria.
extraordinary activity (i.e., hyperactivity),
decreased need for sleep,
may include grandiose plans (i.e., believing that one can accomplish
Speech is typically rapid and may become incoherent, and may involve
a flight of ideas (i.e., attempt to express many ideas at once). MOOD DISORDERS AND SUICIDE - 2
A hypomanic (hypo means below) episode is a less severe version of
a manic episode that does not cause marked impairment in social or
DSM-IV criteria for a manic episode includes:
a. A duration of 1 week; less if the episode is severe enough to
b. Irritability often accompanies the manic episode toward the end
of its duration.
c. Anxiousness and depression are often part of a manic episode.
d. Average duration of an untreated manic episode is 3-6 months.
C. Unipolar disorder refers to the experience of either depression or mania,
and most individuals with this condition suffer from unipolar depression.
However, mania by itself is extremely rare and so unipolar disorder usually
refers to Unipolar Depression.
Bipolar disorder refers to alternations between depression and mania.
Feeling depressed and manic at the same time is referred to as a dysphoric
manic or mixed episode.
II. Depressive Disorders
A. Major depressive disorder, single episode is defined, in part, by the
absence of manic or hypomanic episodes before or during the episode.
The occurrence of 1 isolated depressive episode in a lifetime is rare, and
unipolar depression is almost always a chronic condition that waxes and
wanes over time, but seldom disappears.
Major depressive disorder, recurrent requires that two or more major
depressive episodes that are separated by a period of at least 2 months
during which the individual is not depressed.
Recurrent major depression is associated with a family history of depression.
As many as 85% of single-episode cases later have a second episode of major
1. Mean age of onset is 25 years for persons not in treatment, and 29
years for persons who are in treatment.
2. Incidence of depression and suicide seems to be increasing. MOOD DISORDERS AND SUICIDE - 3
B. Dysthymic disorder shares many of the symptoms of major depression, but
unlike major depression, the symptoms of dysthymia tend to be milder and
remain relatively unchanged over long periods of time, as much as 20 or 30
Dysthymic disorder is defined by persistently depressed mood that continues
for at least 2 years.
During this time, the person cannot be symptom free for more than 2 months
at a time. Many eventually experience a major depressive episode at some
1. Age of onset is typically in the early 20s (i.e., late onset).
2. Onset of dysthymia before age 21 (i.e., early onset) is associated
a. Greater chronicity.
b. Relatively poor prognosis (i.e., response to treatment).
c. Stronger likelihood of the disorder running in the family.
d. Greater prevalence of personality disorders.
C. Double depression refers to both major depressive episodes and dysthymic
Dysthymic disorder often develops first
Associated with severe psychopathology and a problematic future course.
Double depression is quite common, with as many as 79% of persons with
dysthymia reporting a major depressive episode at some point in their lives.
Many do not recover after two years, and relapse rates are very high.
D. The frequency of severe depression following the death of a loved one is
Most mental health professionals do not consider depression associated with
death or loss a disorder unless very severe symptoms appear (e.g., psychotic
features, suicidal ideation, or the less-alarming symptoms last longer than 2
Grief is usually resolved within several months post loss, but may be
exacerbated at significant anniversaries, such as the birthday of the loved one
or during holidays.
If grief lasts longer than 1 year or so the chance of recovering from severe
grief is greatly reduced and mental health professionals may become
concerned. MOOD DISORDERS AND SUICIDE - 4
III. Bipolar Disorders
A. The core identifying feature of bipolar disorders is the tendency of manic
episodes to alternate with major depressive episodes.
Beyond that, bipolar disorders parallel depressive disorders (e.g., a manic
episode can occur once or repeatedly).
B. Bipolar I disorder is the alternation of full manic episodes and major
depressive episodes. The textbook presents the case of Bill to illustrate a full
1. Average age on onset is 18 years, but can begin in childhood.
2. Tends to be chronic.
3. Suicide is a common consequence.
C. In bipolar II disorder, major depressive episodes alternate with hypomanic
episodes. (Book - case of Jane)
Most are female.
1. Average age on onset is 22 years, but can begin in childhood.
2. Only 10 to 13% of cases progress to full bipolar I disorder.
3. Tends to be chronic.
D. Cyclothymic disorder is a more chronic version of bipolar disorder where
manic and major depressive episodes are less severe.
Either a manic or depressive mood state for several years with very few
periods of neutral (or euthymic) mood.
For the diagnosis, the pattern must last for at least 2 years (1 year for
children and adolescents).
Increased risk for developing Bipolar I or II disorder.
1. Average age of onset is about 12 or 14 years.
2. Cyclothymia tends to be chronic and lifelong.
3. Most are female. MOOD DISORDERS AND SUICIDE - 5
E. Differences in the course of mood disorders specify the following:
1. Longitudinal course specifiers are used to address whether a
person has had a past episode of depression or mania and whether the
person recovered fully from past episodes. For example, one should
determine whether dysthymia preceded a major depressive episode or
whether cyclothymic disorder preceded bipolar disorder. Both
scenarios tend to decrease chances of recovery and increase length of
2. Rapid cycling pattern applies only to bipolar I and II disorders.
Rapid cycling pattern is used when a person has at least 4 manic or
depressive episodes within a period of 1 year. Rapid cycling is a more
severe form of bipolar disorder that does not respond well to
treatment. Most of these patterns are severe, seen in females, and
begin with a depressive episode.
3. Seasonal pattern applies to bipolar disorders and recurrent major
depression and is used to indicate whether episodes occur during
certain seasons, usually wintertime. Those with winter depressions
display excessive sleep and weight gain. Seasonal affective disorder
may be related to circadian and seasonal changes in the increased
production of melatonin (i.e., a hormone secreted by the pineal gland).
Phototherapy is a recommended effective treatment for this condition.
IV. Prevalence of Mood Disorders
A. About 7.8% of the North American population report some type of mood
disorder during their lifetime
3.7% over the past year.
Females are twice as likely to have a mood disorder compared to males. The
imbalance between males and females is accounted for solely by major
depressive disorder and dysthymia.
Bipolar disorders are distributed equally between males and females.
B. Mood disorders are fundamentally similar in children and adults. Thus, there
are no childhood mood disorders in the DSM-IV.
However, the clinical presentation of depression does change with age. (chart
on page 208) For instance, children less than 9 years of age show more
irritability and emotional swings rather than classic manic states, and are
often mistaken as hyperactive.
Bipolar disorder also is rare in childhood, but rises substantially in
adolescence and so does suicide. Estimates of the prevalence of mood
disorders in children and adolescents vary widely. The consensus is that
depressive disorder occurs less often in children than adults but that this
difference closes somewhat during adolescence, where depression becomes
more frequent compared to adults. MOOD DISORDERS AND SUICIDE - 6
C. As many as 18% to 20% of elderly nursing home residents may experience
major depressive episodes, which are likely to be chronic.
Late-onset depression is associated with marked sleep problems,
hypochondriasis, and agitation.
It is difficult to diagnose depression in the elderly due to medical illnesses and
symptoms of dementia.
Generally, the prevalence of major depressive disorder is the same or slightly
lower in the elderly than in the general population. Anxiety disorders often
accompany depression in the elderly.
The gender imbalance in depression disappears after age 65.
D. Across cultures, feelings of weakness or tiredness tend to characterize
depression. Prevalence of depression seems to be similar across subcultures,
although more so in economically depressed areas.
E. Some have speculated that mood disorders and creativity are related, even
at the level of genetics. The correlation between famous writers and artisans
and bipolar disorder is one example. (page 211)
F. Substantial overlap exists between the emotional states of anxiety and
depression. Evidence for this is based on neurobiological findings that familial
anxiety is related to familial depression. In addition, drug therapies for both
conditions are similar.
Most persons with depression do display anxiety symptoms, but not all
anxious patients are depressed. Symptoms common to anxiety and
depressive disorders are referred to as negative affect. This may contribute
to the creation of a mixed anxiety/depression diagnosis. Core symptoms of
depression not found in anxiety states include anhedonia (inability to
experience pleasure), psychomotor retardation, and negative cognitive
content. MOOD DISORDERS AND SUICIDE - 7
V. Causes of Mood Disorders
A. Biological dimensions: Familial and genetic influences
1. Family studies indicate that the rate of mood disorders in relatives of
probands (i.e., the person known to have the disorder) with mood
disorders is generally two to three times greater than the rate in
relatives of normal probands. The most frequent mood disorder in
relatives of bipolar patients is unipolar depression, not bipolar
2. Twin studies reveal that if one identical twin presents with a mood
disorder, the other twin is 3 times more likely than a fraternal twin to
have a mood disorder, particularly for bipolar disorder.
Severe mood disorders may have a stronger genetic contribution than
less severe disorders.
Heritability rates being higher for females compared to males. The
environment appears to play a larger role in causing depression in
males than females.
Twin studies also support the contention that unipolar and bipolar
disorder are inherited separately.
3. Data from family, twin, and adoption studies also suggest that the
biological vulnerability for mood disorders may reflect a more general
vulnerability for anxiety disorders as well.
B. Biological dimensions: Neurobiological influences
1. Research indicates low levels of serotonin in the etiology of mood
disorders but only in relation to other neurotransmitters, including
norepinephrine and dopamine. One of the functions of serotonin is to
regulate systems involving norepinephrine and dopamine. The
permissive hypothesis stipulates that when serotonin levels are low,
other neurotransmitters are permitted to range more widely, become
dysregulated, and contribute to mood irregularities.
2. Another theory of depression has implicated the endocrine system,
particularly elevated levels of cortisol. This has led to the
controversial dexamethasone suppression test (DST).
Dexamethasone is a glucocorticoid that suppresses cortisol secretion.
As many as 50% of those with depression, when given
dexamethasone, show less suppression of cortisol. However, persons
with anxiety disorders also demonstrate nonsuppression. MOOD DISORDERS AND SUICIDE - 8
3. Sleep disturbances are a hallmark of most mood disorders.
Depressed persons move into the period of rapid eye movement
sleep (REM) more quickly than nondepressed persons and also show
diminished slow wave sleep (i.e., the deepest and most restful part of
sleep). This REM effect is reduced for persons who have depression
related to recent life stress. REM activity is intense in depressed
persons. Depriving depressed persons of sleep improves their
depression. Persons with bipolar disorder and their children show
increased sensitivity to light (i.e., greater suppression of melatonin
when exposed to light at night). A relationship between seasonal
affective disorder, sleep disturbance, and disturbance in biological
rhythms has thus been proposed.
4. Different alpha electroencephalogram (EEG) values have been
reported in the two hemispheres of brains of depressed persons.
Depressed persons show greater right-side anterior activation of the
cerebral hemispheres (i.e., left-side activation) than nondepressed
persons. This type of brain function may be an indicator of a biological
vulnerability for depression.
C. Psychological dimensions
1. Stressful and traumatic events influence mood disorders, although the
context, meaning, and memory of an event must be considered. In
general, a marked relationship has been found between severe life
events, onset of depression, poorer response to treatment, and longer
time before remission. New research suggests that one third of the
association between stressful life events and depression is due to a
vulnerability whereby depressed persons place themselves in high risk
stressful situations (i.e., reciprocal gene-environment model). In
addition, stressful life events and circadian rhythm disturbances may
trigger manic episodes. However, only a minority of people
experiencing a negative life event develop a mood disorder; therefore,
interaction with a biological vulnerability is likely. The textbook
illustrates the relation between life stress and depression by returning
to a discussion of the case of Katie.
2. According to the learned helplessness theory of depression,
people develop depression and anxiety when they assume they have
no control over life stress. A depressive attributional style has the
following three characteristics.
a. First, the attribution is internal in that one believes negative
events are one's fault.
b. Second, the attribution is stable in that one believes that future
negative events will be one's fault.
c. Third, the attribution is global in that the person believes
negative events will influence many life activities. MOOD DISORDERS AND SUICIDE - 9
d. Evidence is mixed as to whether learned helplessness is a cause
or side effect of depression. Attributions are important as a
vulnerability that contributes to a sense of hopelessness; a
feature that distinguishes depressed from anxious individuals.
3. Aaron T. Beck proposed that depression results from a tendency to
interpret life events in a negative way. Persons with depression often
engage in several co