C HAPTER 8– M OOD D ISORDERS AND S UICIDE
H ISTORICAL PERSPECTIVE
Ancient times: all mental disorders were explained as possession by supernatural forces.
Greek era: mental disorders were explained using scientific approaches
o Hippocrates lived at the time of Hellenic enlightenment, when great advances were made in all
areas of knowledge
o He applied Empedocles’ humoral theory to mental disorders proposed that:
“exaltation” (mania) was caused by an excess of warmth and dampness in the brain
“melancholia” (depression) was caused by an excess of black bile, which could be seen
as a heavy residue in the blood or discolorations on the skin
17 century: clinicians attempted to cure melancholia by draining blood from patients in attempt to
rebalance the body’s humours (i.e. “bloodletting”)
Roman times: philosophers came to recognize the importance of emotional factors in causing depression.
o Cicero stated that “perburtations of the mind may proceed from a neglect of reason”
o Cicero was also the first to suggest psychotherapy as a treatment for melancholia
4 century: Christian church predominated Western thinking, and supernatural explanations for mental
disturbance (e.g. possession by the devil)
o Natural theories of mental illness did not re-emerge in any serious way until the 17 century
o Robert Burton’s Anatomy of Melancholy provided a detailed and scholarly account of the
psychological (e.g. fear, solitude) and social (e.g. poverty) causes of depression that is still read
Modern Age: Emil Kraeplin began the modern age of theories about the etiology of depression.
o Emil defined the word manic-depression and described both depressive and manic forms of this
o His description formed the basis for the definition of the mood disorders contained in DSM-IV-
D IAGNOSTIC ISSUES
Mood disorder: an altered mood state severe enough to interfere with a person’s social and occupational
functioning, and whose range of symptoms is not limited to the person’s feelings, but affects other bodily
and behavioural systems as well.
Common symptoms of depression and mania:
o Feeling sad, depressed, or “down”
o Feel less interested in the things you usually enjoy
o Feeling exhausted or fatigue
o Opposite feelings: excited, “high”, more energy to do activities than usual, etc.
These symptoms demonstrate that almost everyone goes through transient periods of feeling down and
“depressed” as well as through periods of feeling high and “on top of the world”
What distinguishes these feelings from the mood changes seen in clinical mood disorders are: duration
and their severity, and to be diagnosed with mood disorder, several symptoms must co-occur.
o The DSM-IV-TR for major depressive disorder symptoms of depression: Duration – must be present for most of the day, more days than not, for at least two
Severity – require more than an hour to fall asleep every night or nearly every night.
Co-occur – Include nine symptoms of which five must be present to achieve a diagnosis.
Note: DSM-IV-TR criteria represent arbitrary categorical conventions; there is nothing magical about five
symptoms or the duration criteria.
Dr. Kenneth Kendler depression, by its nature, is a continuous phenomenon, and that individuals with
four (or three) symptoms may still suffer considerably.
Mood disorders are classified into two broad categories: unipolar and bipolar.
1. UNIPOLAR M OOD D ISORDERS
Unipolar mood disorders: involve a change in mood in the directions of depression, exclusively in the
Unipolar mania is rarely seen. The two unipolar mood disorders are major depressive disorder and
A) Major Depressive Disorder
Major depressive disorder (MDD): characterized by persistent feelings of sadness, loss of interest or
ability to feel pleasure, unexplained weight loss, difficulty sleeping, fatigue, difficulty concentrating,
feelings of worthlessness or guilt, suicidal thoughts, and either agitation or slowing down.
o often referred to as the “common cold” of mental disorders because it’s so prevalent
It’s the leading cause of disability worldwide and is the second-leading contributor to the global burden of
The use of the word depression when most of us describe feeling “depressed” is referred to very mild and
People with MDD may be accused of “faking it” to get attention and may be labelled as “weak” or even
MDD is a very real and serious disorder that involves abnormalities in all systems (biological,
emotional, cognitive, and behavioural) and can impair functioning in all areas of a person’s life
(physical, occupational, educational, and relational).
To be diagnosed with MDD, the person must show a persistent sad mood and/or a lack of pleasure or
enjoyment in activities for at least two weeks.
o Must be accompanied by at least four additional symptoms, including disturbances in sleeping or
eating (either too little or too much), lack of energy, psychomotor retardation or agitation,
difficulty concentrating or making decisions, feelings of worthlessness or guilt, and thoughts of
death or suicide.
Major depression is a heterogeneous syndrome that has wide individual variability in the symptoms that
are expressed during episodes. Subtypes include:
Has symptoms of extreme anhedonia (i.e. lack of interest or pleasure in people and
These patients’ moods do not brighten in response to positive stimuli (e.g. jokes, good
They display at least three additional symptoms including:
Loss of appetite or significant weight loss
Marked psychomotor retardation or agitation
Diurnal variation (mood is experienced as qualitatively different than loneliness
Controversial topic: some research simply say it represents the severe end of the
continuum of depression and isn’t a qualitatively distinct subtype, but recent research
says it is distinct from other forms of depression
Patients with melancholic depression are more likely than those with non-melancholic to
have a family history of a mood disorder and a history of trauma in childhood.
Melancholic is also less likely to be triggered by severe stress.
2. Atypical (most common subtype)
Involves “reverse vegetative features” – symptoms seen in atypical depression are
opposite to what has historically been seen as “typical” in MDD.
These patients show mood reactivity, such that their mood brightens in response to
They also display:
Increased appetite and weight gain
Hypersomnia (instead of the more typical insomnia)
Leaden paralysis (a heavy, leaden feeling in their arms and legs)
Interpersonal rejection sensitivity
They respond preferentially to the monoamine oxidase inhibitor (MAOI) class of
The depressive episodes of individuals with seasonal affective disorder (SAD) also
involve atypical symptoms.
Patients who experience psychotic symptoms are limited to his or her episode(s) of
Symptoms typically involve:
Delusions and/or hallucinations with depressive themes
o E.g. auditory hallucinations that comment negatively or command the
person to kill themselves.
Persecutory delusional beliefs
o E.g. they are the source of all that is bad in the world
o Helped by low doses of antipsychotic medication in addition to standard
4. Catatonic (very rare) Patients who are characterized by symptoms such as those seen in catatonic
These symptoms must be limited to the patients’ depressive episode(s) to qualify for a
diagnosis of MDD
Motionless for hours at a time
Vigorous, random, or strange movements (e.g. bizarre facial contortions)
Seen most often in the depressive phase of bipolar I disorder
Treatment involves hospitalization and standard pharmacological treatments for mood
disorders. Electroconvulsive therapy is also often used.
Prevalence and Course
MDD affects 5% of the population and often suffer from comorbid mental disorders such as anxiety
o Patients with comorbid disorders experience a more severe and chronic depression, and they
show a slower and less complete response to treatment
Major depression is associated with significant occupational and interpersonal impairments, physical
illness, disability, and death.
Main factor that accounts for the impact of MDD is the disorder’s recurrent course.
Periods of wellness between episodes become shorter and shorter as the disorder progresses; the episode
themselves last between 6-9 months, on average (can last for years).
More and more sufferers are having their first onset at childhood and adolescence.
Adolescence is also the time when sex differences in major depression incidence emerge.
o Dr. Ronald Kessler rates of depression grow steadily and equally for both sexes throughout
childhood but then begin to diverge at about age 10.
o Rates of depression increases for girls throughout adolescence, but drops for boys.
B) Dysthymic Disorder
Dysthymic disorder: chronic low mood, lasting for at least two years, along with at least three associated
Prevalence in the population is about 3% and experience recurrent episodes of MDD superimposed on
their chronic low mood.
Other presentations of chronic low mood are seen clinically:
o Chronic major depression
o Major depression with poor inter-episode recovery
Involves episodes of major depression that fail to remit successfully, thus leading to a chronic dysthymia-
like state between episodes.
Dr. Daniel Klein proposed that chronic depression has:
o higher levels of impairment,
o a younger age of onset,
o higher rates of comorbidity,
o a stronger family history or psychiatric disorder,
o lower levels of social support, o higher levels of stress, and
o higher levels of dysfunctional personality traits than does episodic major depression
individuals with chronic depression are less likely to respond to standard depression treatment than are
those with episodic major depression
Dr. James McCullough developed the Cognitive-Behavioural Analysis System of Psychotherapy(
CBASP) for chronic depression
2. BIPOLAR M OOD DISORDERS
Definition: Mania and Hypomania
Mania: distinct period of elevated, expansive, or irritable mood that lasts at least one week and is
accompanied by at least three associated symptoms.
o Symptoms include:
Decreased need for sleep
Problems with attention and concentration
o Judgment is impaired and these patients may go on spending sprees, engage in substance abuse,
or risky sexual behaviour.
o They may feel special in some way, or they have been “chosen” to fulfill a special mission.
o At first, the symptoms they experience may be enjoyable and intoxicating, feel that they are
energized to get a lot of things done, focused, and these positive side of mania may prevent them
from seeking treatment, or delay medication if they are in treatment.
o As the episode progresses, symptoms may become more severe and start to experience them as
disturbing and frightening; can experience a break with reality or, psychosis.
Hypomania: less severe form of mania that involves a similar number of symptoms to mania, but those
symptoms need to be present for only four days.
o symptoms include high successful productivity
o people with bipolar II are reluctant to take mood-stabilizing medication because they experience
hypomania as enjoyable
For both disorders, the episodes typically last between two weeks and 4 months, while the depressive
episodes last between 6-9 months, as in unipolar depression.
Rates of suicide range between 10-15%, similar to unipolar depression.
Bipolar I and Bipolar II
o An individual has a history of one or more manic episodes with or without one or more major
o Lifetime prevalence rate is about 0.8% (don’t differ between men and women)
o A history or one or more hypomanic episodes with one or more major depressive disorders.
o More difficult diagnose than bipolar I because hypomanic episodes are not as severe as manic
o Lifetime prevalence rate is about 0.5% (don’t differ between men and women) For both:
o DSM-IV-TR states that the mean age of onset is 20 years
o Now, more people are reporting their onset in childhood, and current estimates place prevalence
of 0.5% in children, however, children tend to have a rapid-cycling or mixed-cycling pattern, and
are underdiagnosed due to a lack of understanding about paediatric bipolar disorder.
Cyclothymia: chronic, but less severe form of bipolar disorder – involves a history of at least two years of
alternating hypomanic episodes and episodes of depression that do not need the full criteria for major
Lifetime prevalence is 0.4-1%, and the rate is equal in men and women, but women more often seek
Individuals with Cyclothymia don’t often seek treatment as the mood swings are relatively mild and
hypomanic episodes are enjoyable.
They are at risk for developing full-blown bipolar disorder
Rapid Cycling Bipolar Disorder
Rapid-cycling bipolar disorder: defined as the presence of four or more manic and/or major depressive
episodes in a 12-month period.
the episodes must be separated from each other by at least 2 months of full or partial remission, or by
switch to the opposite mood state (i.e. mania depression, or vice versa)
patients have higher rates of disability and lower rates of response to treatment with this disorder
rapid-cycling can be induced, or made worse, by antidepressant medications
it’s important for patients who are receiving antidepressant treatment to also receive a mood stabilizer
types of cycles:
o ultrarapid – cycling every few days
o ultradian – cycling that occurs daily
^These additional specifiers (descriptors of a patient’s condition) aren’t present in the DSM-IV-TR.
SEASONAL AFFECTIVE D ISORDER
Seasonal affective disorder (SAD): can occur in both unipolar and bipolar disorder and is characterized by
recurrent depressive episodes that are tied to the changing seasons.
o In northern latitudes, episodes generally occur in the winter months
o In southern latitudes, episodes tend to occur in the summer months
11% of patients with major depression have SAD
Prevalence in Canadian population is 2-3% compared with Europe of 1.3-3%.
Early research says the seasonal pattern of SAD focused on melatonin, a hormone that is secreted at night
by the pineal gland
o As the sun provides increased light in the morning, melatonin release is lowered
o This causes body temperature to rise, triggering body processes to move to their awake state
o Patients with SAD may need more light to trigger decreased melatonin secretion o In winter, nights grow longer and melatonin levels remain high, making patients with SAD
continue to sleep or feel drowsy when awake (phenomenon known as “phase-delayed circadian
Lam-Levitan argued that medications that suppress melatonin weren’t defective in relieving symptoms
o The 24-hour winter melatonin rhythm doesn’t differ between individuals with and without SAD
M OOD D ISORDER WITH P OSTPARTUM O NSET
70% of women experience mood swings and feelings of depression up to two weeks after child birth.
In most new mothers these symptoms resolve themselves over time and don’t impair functioning
For some mothers, the mood swings are chronic and severe to meet the criteria for a major depressive or
Common symptoms of mood disorder with postpartum onset include:
o Panic attacks
o Sleep disruption
o Intrusive thoughts about harming themselves or their babies
In rare cases, postpartum mood episodes can include psychotic symptoms such as hallucinations to kill
Postpartum depression affects women similarly across cultures and socio-economic levels
Risk factors include:
o A family history of depression
o A history or previous depressive episodes
o A poor marital relationship and low social support
o Stressful life events concurrent with, or immediately following, childbirth
Progesterone is also a causative factor:
o The waste product of progesterone acts like a barbiturate drug in the brain, and the very rapid
withdrawal of progesterone occur with the delivery of the placenta.
This disorder not only affects the mother, but the current and future children as well.
Postpartum depression also changed women’s future child-bearing plans significantly, choosing adoption,
abortion, or even sterilization.
There is no single cause for the mood disorders, and they’re likely caused by an interaction of a number
of risk factors at a number of levels of analysis.
PSYCHOLOGICAL AND ENVIRONMENTAL C AUSAL F ACTORS
Examines how variables such as temperament and personality, dysfunctional thinking, and maladaptive
interpersonal behaviour patterns contribute to the causes of mood disorders.
First developed by Sigmund Freud and Karl Abraham their model drew a parallel between depression
and grief Freud noted that mourners regress to the oral stage of development, which allows them to regain the lost
loved one symbolically by merging their identities with that of the lost person. If not, then they develop
o Symptoms that are similar in both acute grief and depression include: weeping, loss of appetite,
difficulty sleeping, loss of pleasure in life, and withdrawal.
Individuals most likely become depressed following a loss are those whose needs either were not met or
were excessively met, during the oral stage.
Imagined loss: the individual unconsciously interprets other types of events as severe loss events.
o Even a failure at work could be interpreted as a loss (e.g. loss of esteem)
o These events serve as catalysts for the development of depression
Relationships between parents and children are important in shaping a child’s temperament, and that
neglectful parenting confers a strong risk for later depression.
Individuals with a temperamental vulnerability to depression do interpret life events as having a greater
impact, and these events are more strongly related to depression than they are in individuals who don’t
have this pre-existing vulnerability.
John-Bowlby studied how disruptions in early parent-child attachment could affect personality
development and confer vulnerability to depression. He proposed three styles:
1. Secure attachment: exhibit minimal distress when separated from their moms
2. Avoidant attachment: avoids parents, and when offered a choice, will show no preference
between a caregiver and a complete stranger
3. Anxious/ambivalent attachment: become very distressed when parents leave and cling desperately
to them when they return
These lead to “internal working models”, which guide the individual’s feelings, thoughts, and
expectations in their relationships throughout life.
Aaron T. Beck one’s emotional response to a situation is determined by the manner in which that
situation is appraised or evaluated.
People with depression and people prone to depression, are more likely to appraise situations negatively
than those not prone to depression, and will be more likely to experience negative mood in response to
Cognitive distortions to situations include:
o All-or-nothing thinking: you see things in black-or-white categories. If your performance falls
short of perfect, you see yourself as a total failure.
o Overgeneralization: you see a single negative event as a never-ending pattern of defeat by using
words such as “always” or “never” when you think about it.
o Magnification (catastrophizing): you exaggerate the importance of your errors or problems
o Jumping to conclusions: you interpret things negatively when there are no definite facts to
support your conclusion.
According to Beck’s model, depressed person’s negative cognitive style is the depressive schema – the
o Schemas develop from our early experiences with the world and represent stored memories,
images, and thoughts from these experiences. o Depressed individuals’ schemas consist of tightly interrelated negative core beliefs about the self,
world, and future that are readily activated by events in the environment and impermeable to
Beck’s cognitive model of Diathesis-stress Model proposes that the negative cognitive schemas of the
depression-prone person remain inactive in the mind, and thus serve as silent vulnerability factors that
don’t express themselves until activated by a stressful life event that matches the theme of the schema.
Social signs of depressed people:
o Have deficient social skills in relation to non-depressed people.
o Interactions with others are often negative, involving the exchange of anger and depressed
o Engage less in frequent eye contact, have less animated facial expressions, and show less
modulation in their tone of voice.
A particular type of impaired social skill – negative feedback seeking – may serve as a risk factor for
o Negative feedback seeking: tendency to actively seek out criticism and other negative
interpersonal feedback from others
o This theory states that the need to obtain this info, which is consistent with the depressed person’s
own self-schemas, overrides the pain of receiving negative feedback.
Excessive interpersonal dependency, excessive need for interpersonal attachment, support, and
acceptance leads to behaviours that cause and maintain depression.
Excessive reassurance seeking: tendency to repeatedly seek assurance about one’s worth and lovability
from others, regardless of whether such assurances have already been provided.
o Coyne’s interpersonal model of depression: the depression-prone person may excessively seek
reassurance after a negative event, such as an argument.
o Even when given reassurance, the depressed person doubts its sincerity and continues to demand
Stress generation hypothesis: depressed individuals have been found to generate and contribute to the
occurrence of stressful life events in the interpersonal domain, including fights, arguments, and
Life Stress Perspective
Stressful life events tax our psychological and physical resources and can cause significant increases in
sadness, anxiety and irritability.
Stressful life events for some people can trigger a downward spiral into major depression focusing on
What characteristics of life events are most strongly associated with major depressions?
What characteristics of individuals place them at risk for developing major depression in the face
of life events?
What characteristics of individuals confer resilience in the face of life events?
Individuals with depression were nearly 3x more likely than those without depression to have experienced
a stressful life event prior to onset Nearly 75% of major depressed people have suffered at least one severe loss event in the 3-6 months prior
to onset of their depression.
Certain individuals possess characteristics that predispose them to be more sensitive to the effects of
stressful life events
A study of monozygotic and dizygotic twin pairs found that individuals at the highest genetic risk
for depression were more than twice as likely to develop depression in the face of a severe life
event; the genetic risk sensitized these high-risk individuals
B IOLOGICAL C AUSAL FACTORS
Both unipolar major depression and bipolar disorder run in families and this is evident by interviewing
family members of people who have the disorder
It is estimated that first degree relatives of people with unipolar depression are 2-5 times more likely to
develop depression than are individuals from the general population
For bipolar disorder, the link is even stronger – first degree relatives of people with bipolar have a 7-15
times greater risk of developing any mood disorder than the general population
However, these studies don’t prove that this link is genetic; family members also share the same
environment, and environmental influences are very strong in promoting risk for mood disorders
o Environmental vs. genetic contributions to mood disorders:
Adoption study – higher rates for bipolar disorder in biological parents of affectively ill
adoptees compared to the adoptive parents
Twin study – identical twins share 100% of their genetic material, whereas fraternal twins
share 50% just like regular siblings. MZ twins have higher rates than DZ twins for
bipolar disorder and unipolar major depression
Hereditary estimates are an indication of the relative contributions of differences in
genetic and non-genetic factors to the total variance in the disorder in a population.
There is no single “mood disorder gene”, but the alleles, located