CHAPTER 7

MOOD DISORDERS AND SUICIDE

CHAPTER OVERVIEW
This chapter outlines the characteristic features of mood disorders (i.e., depression and
mania). Specifically, the epidemiology, etiology, and treatment of major depressive episodes,
dysthymia, cyclothymia, and bipolar disorder I and bipolar disorder II are described. Symptom
feature modifiers, or those additional factors that have implications for predicting course or
response to treatment, are also covered. The chapter is also devoted to the phenomenon of
suicide, including prevention and intervention of suicidal ideation and intent. Various clinical
examples are presented throughout the chapter.

LEARNING OBJECTIVES
1. Differentiate a depressive episode from a manic and hypomanic episode.
2. Describe the clinical symptoms of major depression.
3. Describe the clinical symptoms of bipolar disorder, including mania.
4. Differentiate major depression from dysthymic disorder.
5. Differentiate bipolar disorder from cyclothymic disorder.
6. Understand the different symptoms and longitudinal course specifiers for mood
disorders, including their relation with prognosis and treatment.
7. Describe the differences in prevalence of mood disorders across the lifespan.
8. Describe the biological, psychological, and sociocultural contributions to the
development of unipolar and bipolar mood disorders, including what is known
about such disorders in children.
9. Describe medical and psychological treatments that have been successful in
treating mood disorders.
10. Describe the relationship between suicide and mood disorders.
11. Elucidate known risk factors for suicide and approaches to suicide prevention and
treatment.

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 LECTURE OUTLINE
I. Understanding and Defining Mood Disorders
A. An overview of depression and mania
1. The disorders described in this chapter used to be called ―depressive
disorders,‖ ―affective disorders,‖ or even ―depressive neuroses.‖ Beginning
with the DSM-III, these problems were grouped under the heading mood
disorders because they all represent gross deviations in mood.
2. The experience of depression and mania contribute, either alone or in
combination, to all mood disorders.
3. A major depressive episode is the most commonly diagnosed and most
severe form of depression (see DSM-IV-TR diagnostic criteria for major
depression). The textbook illustrates clinical depression with the case of
Katie. DSM-IV-TR criteria for major depressive episode includes:
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 activities.
e. Average duration of an untreated major depressive episode is 4 to 9
months.
4. Mania refers to abnormally exaggerated elation, joy, or euphoria. Such
episodes are accompanied by extraordinary activity (i.e., hyperactivity),
require decreased need for sleep, and may include grandiose plans (i.e.,
believing that one can accomplish anything). Speech is typically rapid and
may become incoherent, and may involve a flight of ideas (i.e., attempt to
express many ideas at once). A hypomanic (hypo means below) episode is a
less severe version of a manic episode that does not cause marked impairment
in social or occupational functioning. DSM-IV-TR criteria for a manic
episode includes:
a. A duration of 1 week; less if the episode is severe enough to require
hospitalization.
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.

 DISCUSSION POINT:
Many people with bipolar disorder demonstrate poor insight during manic episodes.
How might the experience of a manic episode be reinforcing, and what are the
implications for treatment?

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B. The structure of mood disorders
1. Unipolar disorder refers to the experience of either depression or mania, and
most individuals with this condition suffer from unipolar depression. Bipolar
disorder refers to alternations between depression and mania.
2. Feeling depression and mania at the same time is referred to as a dysphoric
manic or mixed episode; in these episodes, patients usually feel as if their
mania is out of control, and become anxious or depressed regarding this
experience. A recent study indicated that 30% of patients hospitalized for acute
mania actually had mixed episodes.
3. Almost all major depressive episodes remit without treatment. Manic
episodes remit without treatment after six months. Thus, it is important to
determine the course or temporal patterning of the depressive and manic
episodes. Different patterns appear in the DSM-IV-TR under the heading
course modifiers for mood disorders.
a. Course modifiers characterize the past mood state and are helpful to
predict the future course of the disorder. Understanding the course is
related to predicting future occurrences of mood changes and in
helping to prevent them.

C. Depressive disorders
1. 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 one 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.
2. Major depressive disorder, recurrent requires that two or more major
depressive episodes occur and are separated by a period of at least 2 months
during which the individual is not depressed. As many as 85% of single-
episode cases later have a second episode of major depression. The median
lifetime number of major depressive episodes is four, and the median duration
is 4 to 5 months.
3. Dysthymic disorder shares many of the symptoms of major depressive, but
unlike major depression, the symptoms in dysthymia tend to be milder and
remain relatively unchanged over long periods of time, as much as 20 or 30
years. 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. One 10-year study indicated
that 22% of those suffering from dysthymia eventually experienced a major
depressive episode.
4. Double depression refers to both major depressive episodes and dysthymic
disorder. Dysthymic disorder often develops first, and this condition is
associated with severe psychopathology and problematic future course.
Indeed, many do not recover after two years, and relapse rates are very high.
5. The risk for developing depression is low until the early teens, when it begins
to rise; the mean age of onset is 30. There is some evidence that the risk of
developing depression while younger is on the increase. Untreated depression

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 does tend to remit, but residual symptoms may leave the individual vulnerable
to later episodes.
6. The mean age of onset for dysthymia is typically in the early 20s (i.e., late
onset). The onset of dysthymia before age 21 (i.e., early onset) is associated
with (a) greater chronicity, (b) relatively poor prognosis (i.e., response to
treatment), and (c) stronger likelihood of the disorder running in the family.
The median duration of dysthymic disorder is approximately 5 years in adults
and 4 years in children. Patients suffering from dysthymia have a higher
likelihood of attempting suicide than those suffering from major depressive
disorder.
7. Double depression is common, with as many as 79% of persons with
dysthymia reporting a major depressive episode at some point in their lives.
8. The frequency of severe depression following the death of a loved one is
quite high, around 62%. 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 that last longer than 2 months). 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.
a. 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.
b. A history of major depressive episodes may predict the development
of a pathological grief reaction or impacted grief reaction, which
include symptoms of intrusive memories and strong yearnings for the
loved one, and avoiding people and places associated with the loved
one. Around 10-20% of bereaved individuals may experience this
reaction, which is associated with suicidal thoughts, despite not having
been depressed previously. Some theorists suggest that pathological
grief be diagnostically distinct from major depression.
c. A new study has indicated that treatment of pathological grief
involving finding meaning in the loss, incorporating positive emotions
into the grief, and finding ways to cope shows better outcomes than
interpersonal therapy.

D. Bipolar disorders
1. 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). The textbook presents the case of Jane to illustrate Bipolar II
disorder.
2. Bipolar I disorder is the alternation of full manic episodes and depressive
episodes. The textbook presents the case of Billy to illustrate a full manic
episode.
a. Average age of onset is 18 years, but it can begin in childhood.
b. Tends to be chronic.

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 c. Suicide attempts are estimated to occur in 17% of patients, usually in a
depressive episode.
3. In bipolar II disorder, major depressive episodes alternate with hypomanic
episodes.
a. Average age of onset is 19-22 years, but it can begin in childhood.
b. Only 10 to 13% of cases progress to full bipolar I disorder.
c. Tends to be chronic.
d. Suicide attempt rates are estimated at 24%.
4. Although major depression and bipolar disorder were once thought to be
distinct conditions, some studies have indicated that about 25% of depressed
individuals may go on to experience a full manic episode, with over two-
thirds of depressed individuals endorsing some manic symptoms. Thus, these
conditions may be best described as existing on a continuum.
5. Completed suicide in bipolar disorder is 4 times more common than in
recurrent major depression. Long-term studies show completed suicide rates
of 8-11% in bipolar disorder.

 DISCUSSION POINT:
Why might bipolar disorder confer a higher risk for suicide than major depression?

6. Cyclothymic disorder is a more chronic version of bipolar disorder where

manic and major depressive episodes are less severe. Such persons tend to
remain in 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). Such persons are
also at increased risk for developing bipolar I or II disorder.
a. Average age of onset is about 12 or 14 years.
b. Cyclothymia tends to be chronic and lifelong.
c. Most are female.

E. Additional defining criteria for mood disorders

1. Symptom specifiers are often helpful in determining the most effective
treatment and are of two broad types: those that describe the most recent
episode of the disorder, and those that describe its course of temporal pattern.
2. Specifiers for recent episodes include the following:
a. Atypical features specifier modifies depressive episodes and
dysthymia but not manic episodes. Individuals with this specifier
oversleep, overeat, gain weight, and show much anxiety. These persons
are able to experience some pleasure in their lives. Depression with
atypical features is associated with an earlier age of onset and a greater
percentage of women.

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 b. Melancholic features specifier applies only if the full criteria for a
major depressive episode have been met; it does not apply to
dysthymia. This group includes more severe somatic symptoms (e.g.,
early morning awakenings, weight loss, loss of sex drive, excessive
guilt, and anhedonia) and indicates a more severe type of depressive
episode.
c. Chronic features specifier can be applied only if the full criteria for
major depressive episode have been met continuously for at least the
past 2 years. Does not apply to dysthymic disorder.
d. Catatonic features specifier applies to major depressive episodes and
manic episodes, though it is very rare. This is a very serious condition
involving the total absence of movement (i.e., a stuporous state) or
catalepsy (i.e., muscles are waxy and semi-rigid). Catalepsy is seen as
a reaction to imminent doom, similar to animals about to be attacked.
e. Psychotic features specifier applies to cases where psychotic
symptoms (i.e., hallucinations, delusions) are experienced during the
major depressive or manic episode. Hallucinations and delusions may
be mood congruent (i.e., symptom content are directly related to
depressed mood) or mood incongruent. Examples of these symptoms
include auditory hallucinations and somatic or grandeur delusions.
Psychotic depressive episodes are rare but associated with poor
response to treatment.
f. Postpartum onset specifier applies to both major depressive and
manic episodes and is used to characterize severe manic or depressive
episodes of a psychotic nature that first occur during the postpartum
period (i.e., 4-week period immediately following childbirth). 13% of
women giving birth meet criteria for a major depressive episode. This
specifier is not applied to mild depressive episodes following
childbirth. Although postpartum depression has been thought of as a
female phenomenon, one recent study found that 10% of mothers had
an increase in depression after childbirth, but so did 4% of fathers.

 DISCUSSION POINT:
What are some of the possible explanations for postpartum onset of depression, in
both mothers and fathers?

3. Specifiers describing the course of mood disorders include the following:

a. 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
treatment.

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 b. 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,
and appears to be associated with higher rates of suicide. Alternative
drug treatments (e.g., anticonvulsants, mood stabilizers) are typically
utilized with individuals meeting criteria for this specifier. Around 20-
40% of bipolar patients experience rapid cycling, and 60-90% of these
are female. Most people with rapid cycling begin with a depressive
episode, rather than a manic episode.
c. 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,
although CBT may show better long-term results in terms of
preventing recurrence of seasonal depression.

II. Prevalence of Mood Disorders

A. About 13-16.6% of individuals experience some type of mood disorder during
their lifetimes, with 5.2-6.7% in 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. The prevalence of
major depressive disorder and dysthymia is also significantly lower among African
Americans than European Americans and Hispanics, although once again, this
difference is not seen for bipolar disorders. Native Americans seem to have higher
prevalence rates of major depression.

B. Mood disorders are fundamentally similar in children and adults. Thus, there are
no childhood mood disorders in the DSM-IV-TR. How depression presents does
change with age. 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.
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 is rare in childhood, but rises substantially in adolescence, as does suicide.

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 in

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 the elderly is about half that in the general population. Anxiety disorders often
accompany depression in the elderly. Menopause may increase rates of depression
among women who have never previously been depressed, which may be due to
biological factors or life changes. The gender imbalance in depression disappears
after age 65.

D. Across cultures, feelings of weakness or tiredness tend to characterize depression.

However, more difficulty is found when comparing subjective feelings that
accompany depressive disorders. Societies that are more individualistic tend to
produce depressive statements with the "I" pronoun, whereas societies that are
more integrated focus on "our" statements. Still, the prevalence of depression
seems to be similar across subcultures, although more so in economically
depressed areas.

E. Speculation has been made as to whether mood disorders and creativity are
related, possibly genetically. The correlation between famous writers and bipolar
disorder is one example.

 DISCUSSION POINT:
What are the possible explanations for the overlap between creativity and mood
disorders?

In addition to biological theories, have students to discuss how the experience of a mood
episode may influence the creative process. Is it possible that engaging in creative
activities may be a form of ―self-medication‖?

III. The Overlap of Anxiety and Depression

A. The overlap between depression and anxiety has caused researchers to theorize
about why these two conditions tend to correlate. Specifically, almost all
depressed individuals show anxiety, but not all anxious individuals show signs of
depression. There seem to be core features of depression such as anhedonia and
depressive slowing of motor and cognitive functions that represent what is pure
about depression as a construct.

B. Some features of panic and anxiety may also be seen in depression, with people
endorsing such symptoms labeled as having ―agitated depression.‖ Symptoms
common to both depression and anxiety are called negative affect, which may
form the basis of a new diagnosis of mixed anxiety and depression.

IV. Causes of Mood Disorders

A. Biological dimensions
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

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 most frequent mood disorder in relatives of persons suffering from mood
disorders is unipolar depression.
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. There also appear to
be sex differences in genetic vulnerability to depression, with 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. Studies now indicate the contribution of a small group of genes
that explain heritability of some types of depression.
3. Data from family and twin studies also suggest that the biological
vulnerability for mood disorders may reflect a more general vulnerability for
anxiety disorders as well.
4. Many reports indicate neurotransmitter systems in the etiology of depression.
Research indicates low levels of serotonin in the cause 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.
5. Another theory of depression has implicated the endocrine system,
particularly elevated levels of cortisol. Cortisol and other neurohormones are
a key focus of study in psychopathology. This area of research 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.
New research findings indicate that elevated levels of stress hormones in the
long term may interfere with the production of new neurons (i.e.,
neurogenesis), especially in the hippocampus, which may result in disrupted
memory processes.
6. 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.

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B. Brain wave activity
1. 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., less left-
side activation and less alpha wave activity) than non-depressed persons. This
type of brain function may be an indicator of a biological vulnerability for
depression, as it is seen in adolescent offspring of depressed mothers.

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.
3. Studies indicate that negative cognitive styles precede, and thereby operate as
a risk factor for, depression.
4. Attributions are important as a vulnerability that contributes to a sense of
hopelessness; a feature that distinguishes depressed from anxious individuals.
5. 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
cognitive errors and think the worst of everything. The following examples
of cognitive errors are illustrated in the textbook:
a. Arbitrary inference refers to the tendency of depressed persons to
emphasize the negative rather than positive aspects of a situation.
b. Overgeneralization refers to the tendency to take one negative
consequence of some event and generalize to all related aspects of the
situation.
6. According to Beck, persons with depression make such cognitive errors all the
time, as represented in thinking negatively about themselves, their immediate
world, and their future (called the depressive cognitive triad). These beliefs

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 may comprise a negative schema, or an automatic and enduring cognitive bias
about aspects of life. Substantial empirical evidence supports this theory.
7. Current integrative models of cognitive vulnerability for depression implicate
both learned helplessness and negative cognitive styles as risk factors for
depression. One study has demonstrated that negative cognitive styles do
confer vulnerability for later depression.

D. Social and cultural dimensions

1. Marital dissatisfaction and depression are strongly related, and marital
disruption often precedes depression. This seems particularly true for men. In
addition, high marital conflict and/or low marital support are important in the
etiology and recurrence of depression. Conversely, continuing depression may
lead to the deterioration of a marital relationship.
2. Gender imbalances occur across the mood disorders (with the exception of
bipolar disorder) and this is a world-wide phenomenon. Around 70% of
people with major depressive disorder and dysthymia are women. Several
theories have arisen to explain this gender disparity:
a. One theory involves perceptions of uncontrollability. Such perceptions
are strongly influenced by socialization, where females are expected to
be passive and sensitive to others.
b. A surge of depression among girls during puberty may be related to
stresses of entering a new school; girls who mature physically early
have more risk for depression than others.
c. Females may place more emphasis on intimate relationships and be
more disturbed by problems in this area than males. Females may also
be self-deprecating in times of stress.
d. Females are subjected to more discrimination, poverty, sexual
harassment, and abuse than males.
3. The number and frequency of social relationships and contact may be related
to depression. A lack of social support appears to predict the later onset of
depressive symptoms, and high expressed emotion (patterns of interaction
characterized by criticism, blame, and conflict) or dysfunctional families may
predict relapse. Conversely, substantial social support is related to rapid
recovery from depression.

E. An integrative theory of the etiology of mood disorders

1. Depression and anxiety may share common biological/genetic vulnerabilities,
such as an overactive neurobiological response to stressful life events.
2. Psychological vulnerabilities, such as attributions, correlate highly with
biochemical markers. Childhood adversity and exposure to depressed
caregivers may be related to the later development of mood disorders.
3. The onset of stressful life events may then activate stress hormones that affect
certain neurotransmitter systems, including turning on certain genes. Extended
stress may also affect circadian rhythms and activate a dormant psychological
vulnerability characterized by negative thinking and a sense of helplessness
and hopelessness.

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 4. In addition, psychological vulnerabilities such as feelings of uncontrollability
may be triggered. All of this is dependent, however, on mediating
environmental factors such as interpersonal relationships.

V. Treatment of mood disorders

A. Three types of antidepressant medications are used to treat depressive disorders:
1. Tricyclic antidepressants are widely used treatments for depression, and
include imipramine (Tofranil) and amitriptyline (Elavil). It is not yet clear
how these drugs work, but initially at least they block the reuptake of
norepinephrine and other neurotransmitters (i.e., down-regulation). This
process may take anywhere between 2 to 8 weeks, and patients often feel
worse and develop side-effects before feeling better. Side-effects include
blurred vision, dry mouth, constipation, difficulty urinating, drowsiness,
weight gain, and sexual dysfunction. Because of the side-effects, about 40% of
patients stop taking the drugs. Tricyclics alleviate, but do not eliminate,
depression in 50% of cases compared to 25-30% of people taking placebo.
Tricyclics may be lethal in excessive doses.
2. Monoamine oxidase (MAO) inhibitors work by blocking an enzyme
monoamine oxidase that breaks down serotonin and norepinephrine. MAO
inhibitors are slightly more effective than tricyclics and have fewer side-
effects. However, ingestion of tyramine foods (e.g., cheese, red wine, beer) or
cold medications with the drug can lead to severe hypertensive episodes and
occasionally death. New MAO inhibitors (not yet available in the U.S.) are
more selective, short acting, and do not interact negatively with tyramine.
Use of MAO inhibitors has decreased significantly in recent years.
3. Selective serotonergic reuptake inhibitors (SSRIs) specifically block the
pre-synaptic reuptake of serotonin, thus increasing levels of serotonin at the
receptor site. Fluoxetine (Prozac) is the best known SSRI. Risks of suicide or
acts of violence are no greater with Prozac than with any other antidepressant
medication in adults. In adolescents, the data are mixed regarding whether or
not SSRIs are related to suicidality, leading to an FDA warning. It is possible
that SSRIs confer an initial risk of suicidal thoughts (in the first few weeks),
but later are related to decreased suicidality. Common side-effects of Prozac
are physical agitation, sexual dysfunction or low desire, insomnia, and
gastrointestinal upset.
4. Newer antidepressants, such as Venlafaxine and Nefazodone work on slightly
different mechanisms than other SSRIs, and are comparable to effectiveness
of older antidepressants.
5. St. John’s Wort (hypericum) is receiving increasing attention as an herbal
solution for depression. Preliminary studies suggested that St. John’s Wort
works better than placebo in alleviating depression and works as well as low
doses of other antidepressant medications, although a recent NIH study found
no benefit of the drug. St. John’s Wort also appears to alter serotonin function
and has few side-effects.

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 6. A recent study indicated that there is some benefit of switching from one
medication to another in cases of persistent depression, with some people
benefiting from the change to a second drug or addition of a second drug.
7. Current studies indicate that these drug treatments are effective with adults,
but not necessarily with children, and may cause substantial negative side-
effects in children. Similar concerns are evident for the elderly population.
Overall, recovery from depression may not be as important in treatment as
preventing the next episode of depression from occurring. Drug treatment is
typically extended well past the end of a patient's current depressive episode.
8. It is important to note that approximately 30% of depressed persons do not
respond to these medications, and females of childbearing age must avoid
conceiving while taking antidepressants.
9. Lithium is a common salt found in the natural environment, including
drinking water. Lithium has historically been the primary drug of choice in
the treatment of bipolar disorder. Side-effects may be severe, and dosage must
be carefully regulated to prevent toxicity (poisoning) and lowered thyroid
functioning. Substantial weight gain is also a common side-effect. Debate
exists as to how lithium works, but possibilities include the reduction of
dopamine and norepinephrine or changes in neurohormones. About 30-60%
of persons with bipolar disorder respond well to lithium treatment.
10. In other cases of bipolar disorder, antiseizure medication may be effective.
Valproate, an anticonvulsant has recently overtaken lithium as the most
frequently prescribed mood stabilizer, and is equally effective in reducing
mood cycling, though it does not prevent suicide as well as lithium.
11. Regardless of the actual drug used for treatment of bipolar disorder, many
patients are noncompliant or discontinue their medications, possibly because
of the ―high‖ many experience during manic states.

B. Electroconvulsive therapy (ECT) is the treatment of choice for very severe

depression. The patient is anesthetized and is given muscle-relaxing drugs to
prevent bone breakage from convulsions during seizures and is then administered
a brief (less than 1 second) electric shock introduced to the brain. The result is
brief convulsions lasting for several minutes. Treatments are usually
administered once every other day for a total of 6 to 10 treatments. Side-effects
are few and are limited to short-term memory loss and confusion, both of which
usually disappear after a week or two. Approximately 50% of persons not
responding to medication benefit from ECT. However, relapse is extremely
common, necessitating follow-up with antidepressant drugs. The mechanism of
action for ECT is unclear. Transcranial magnetic stimulation (TMS) is a new
procedure that is related to ECT, but involves setting up a strong magnetic field
around the brain. Mixed data exist regarding whether TMS is superior to ECT.

 DISCUSSION POINT:
Have students talk about their perceptions of ECT and where those perceptions
originated. Encourage them to discuss how the actual practice of ECT may be similar
to, and different from, their preconceived notions.

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C. Some non-drug biological approaches are also in development, such as implanting
a transmitter that stimulates the vagus nerve, thought to influence
neurotransmitter production. Deep brain stimulation via electrodes in the limbic
system is also a possible approach. Both of these treatments are for treatment-
resistant depression.

D. At least three major psychosocial treatments are available for depressive

disorders.
1. Aaron Beck's cognitive therapy involves teaching clients to examine the types
of thinking processes they engage in while depressed and recognize cognitive
errors when they occur. Clients are informed about how these processes lead
to depression and faulty thinking patterns are modified. Clients also monitor
and record their thoughts between therapy sessions and are assigned homework
to change their behavior. Increased behavioral activity to elicit social
reinforcement and to test hypotheses about the world is also mandated.
Treatment usually takes 10 to 20 sessions. The textbook illustrates Beck’s
cognitive therapy with a dialogue between Beck and a patient named Irene.
2. Lewinson and Rehm developed a form of cognitive-behavior therapy for
depression that focused initially on reactivating depressed patients and
countering their mood by bringing them in contact with reinforcing events.
More recent approaches have also stressed the preventing avoidance of social
and environmental cues that produce negative affect or depression.
3. It is possible that increased activities alone may improve self-concept and lift
depression, suggesting that the behavioral component of CBT may be the
active ingredient of treatment.
4. Interpersonal therapy (IPT) focuses on resolving problems in existing
relationships and/or building skills to develop new relationships. Like
cognitive-behavioral approaches, IPT is highly structured and seldom takes
longer than 15 to 20 weekly sessions. The therapist and client identify life
stressors that precipitate depression, and then address interpersonal role
disputes, adjustments to losing a relationship, acquisition of new relationships,
and social skills deficits.
5. Recent studies comparing the results of cognitive therapy and IPT to those of
tricyclic antidepressants and other control conditions for major depressive
disorder and dysthymia have shown that psychosocial approaches and
medication are equally effective, and that all treatments are better than
placebo and brief psychodynamic therapy.

E. Prevention programs involve different interventions to instill social skills and

improve communication. Some of these interventions have involved pregnant
women, attempting to reduce the incidence of postpartum depression. Initial
results are promising, though some studies indicate the importance of focusing on
at-risk individuals alone.

F. Current data suggest that combining medication and psychosocial treatments

may provide an added benefit over providing each treatment alone. However,

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 combining two treatments is expensive, and as an alternative, one treatment may
be tried first before adding the other.

G. Psychosocial interventions (i.e., cognitive therapy and IPT) seem helpful in

preventing relapse. In a recent study, cognitive therapy showed an enduring effect
over medication in preventing later recurrence of depression.

H. Though medication is the preferred treatment for bipolar disorder, most

clinicians emphasize the need for psychosocial interventions to manage
interpersonal and practical problems, particularly noncompliance with medication
regimen and family stress that has been shown to be related to increased risk of
relapse. A new approach called interpersonal and social rhythm therapy (IPSRT)
focuses on helping patients to regulate their sleep cycles and schedules while also
improving relationships. IPSRT has shown a benefit in reducing the frequency of
manic and depressive episodes. Family therapy may also be beneficial for bipolar
disorder.

VI. Suicide
A. Suicide is the eighth leading cause of death in the United States, although many
unreported suicides occur.

B. Suicide is overwhelmingly a white phenomenon and African Americans and

Hispanics seldom commit suicide. Suicide rates are also quite high in Native
Americans, though rates vary considerably from tribe to tribe.

C. The rate of suicide is increasing, especially among adolescents and the elderly.
White men are at highest risk, particularly men over 65. However, in China,
females commit suicide more often than males, and the reason seems related to the
absence of stigma about suicide in Chinese society (i.e., it is viewed as honorable
and a reasonable solution to problems).

D. Suicidal ideation refers to serious contemplation about committing suicide,

whereas suicidal attempt refers to surviving an attempted suicide. Males are 4-5
times more likely to commit suicide than females, although females are three times
more likely to attempt suicide than men. This is explained by the fact that men
choose more lethal methods of suicide than women.

E. Emile Durkeim, a sociologist, defined a number of suicide types related to the

cause of suicide:
1. Formalized or altruistic suicide is socially or familially sanctioned (e.g.,
killing oneself to avoid dishonor to self or family).
2. Egoistic suicide, which may be common in the elderly, is suicide caused by
disintegration of social support.
3. Anomic suicides occur following some major disruption in one's life (e.g.,
sudden loss of a high prestige job). Anomie means lost and confused.

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 4. Fatalistic suicides refer to suicide related to a loss of control over one's
destiny (e.g., mass suicide of Heaven’s Gate cult members).

F. Freud believed that suicide was the result of unconscious hostility expressed
inwardly to the self.

G. Factors related to suicide have been investigated through the use of a

psychological autopsy, studying conditions related to an individual’s suicide.
Risk factors for suicide include the following:
1. If a family member commits suicide, there is an increased risk that someone
else in the family will also do so. Both learned behavior and inherited traits,
such as impulsivity, may account for this finding.
2. Low levels of serotonin may be associated with suicide and with violent
suicide attempts. Low levels of serotonin are associated with impulsivity,
instability, and the tendency to overreact to situations.
3. Existence of a psychological disorder is related to suicide, as over 90% of
people who kill themselves suffer from a psychological disorder. As many as
60% of suicides occur in persons suffering from a mood disorder. Depression
and suicide are still considered independent, as suicide can occur without a
mood disorder, and not all persons with mood disorders try to kill themselves.
4. Alcohol use and abuse are associated with 25% to 50% of suicides.
5. Past suicide attempts is another strong risk factor in predicting subsequent
suicide attempts; one study found a 30-fold increase in the risk of completed
suicide among individuals with prior deliberate self-harm.
6. Most important risk factor for suicide is a severe, stressful event that is
experienced as shameful or humiliating.

H. Publicity about suicide appears to increase rates of suicide, and clusters of suicides
(i.e., several people copying one person who committed suicide) seems
predominate in teenagers. The reasons for imitation or modeling of suicide are
complex, but may be due to the media romanticizing suicide and the media
spelling out methods used to commit suicide.

I. Predicting suicide is difficult, but mental health professionals routinely assess for
suicide, often directly via intent, a plan, and a means to carry it out. In general, the
more detailed the plan, the more one is at risk for committing suicide. A suicide
contract may be used to prevent a patient from killing him or herself, and at times,
hospitalization is required. Programs to reduce suicide include curriculum-based
programs that are designed to educate students about suicide and to provide means
for handling stress. Data indicate that asking people about suicide does not seem
to ―put the idea in their heads.‖

J. Treatments for persons at risk for suicide may employ a problem-solving

cognitive-behavioral intervention, coping-based interventions, and stress reduction
techniques. One recent study indicated that 10 sessions of cognitive therapy for

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 recent suicide attempters cuts the risk of additional suicide attempts by 50% over
the next 18 months.

VII. Future research in mood disorders will inevitably involve the connections between
biological and psychological processes, as recent studies indicate that biological
variability and psychological vulnerability may work in conjunction with one another.

KEY TERMS
Bipolar I disorder (p. 215)
Bipolar II disorder (p. 215)
Catalepsy (p. 218)
Cognitive therapy (p. 243)
Cyclothymic disorders (p. 216)
Delusions (p. 218)
Depressive cognitive triad (p. 234)
Double depression (p. 211)
Dysphoric manic or mixed episode (p. 209)
Dysthymic disorder (p. 210)
Electroconvulsive therapy (ECT) (p. 242)
Hallucinations (p. 218)
Hypomanic episode (p. 209)
Interpersonal psychotherapy (p. 244)
Learned helplessness theory of depression (p. 233)
Maintenance treatment (p. 246)
Major depressive disorder, single or recurrent episode (p. 210)
Major depressive episode (p. 208)
Mania (p. 208)
Mood disorders (p. 208)
Neurohormones (p. 230)
Pathological or impacted grief reaction (p. 214)
Psychological autopsy (p. 251)
Seasonal affective disorder (p. 220)
Suicidal attempts (p. 250)
Suicidal ideation (p. 250)

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 INFOTRAC KEY TERM EXERCISES
Each exercise is linked to key terms from the Wadsworth InfoTrac online searchable
database. Key terms must be entered exactly as written.

Exercise 1: Use of Electroconvulsive Therapy in Children: Is it Safe and Does it Work?

Article: A19912690
Citation: (Use of electroconvulsive therapy with children: an overview and case report.)
Catherine L. Willoughby; Elizabeth A. Hradek; Nancy R. Richards.
Journal of Child and Adolescent Psychiatric Nursing, July-Sept 1997 v10 n3
p11(7).
Your textbook notes that Electroconvulsive Therapy (ECT) is efficacious as a late
line treatment for severe cases of adult depression. Increasingly, however, ECT is being used
with children and adolescence. This InfoTrac article reviews research using ECT in children and
adolescents, and then provides limited data on the use of ECT with an 8-year-old girl who
suffered from psychotic depression. You are to review this article and address the follow ing
questions: (a) What is the state of research evidence supporting ECT in children and adolescents?
(e.g., how many studies, does ECT work and for what age group), (b) Describe guidelines for use
of ECT in children/adolescents. (c) Provide a summary of the case report that follows. Was ECT
effective for this young girl? Knowing what you know about ECT, what kinds of concerns
would you have about its use with small children and young adolescents? Limit your answer to
3-5 typed double-spaced pages.

Exercise 2: Facts About St. John’s Wort in the Treatment of Depression

Key Term: St. John's Wort, Subdivision, Evaluation
St. John’s Wort is receiving increasing attention as a viable over-the-counter solution for
the treatment of depression. St. John’s Wort is available without a prescription at most health
food stores and pharmacies. Your task here is to evaluate the current evidence regarding the
effectiveness of St. John’s Wort as a treatment for depression, including the known
contraindications and side-effects. In so doing, think whether the evidence is there to warrant
consumers or physicians turning to St. John’s as a solution for depression. Review the InfoTrac
article(s) on this topic and provide a review and case for or against the utility of St. John’s Wort,
backed by appropriate evidence. Limit your answer to 3-5 typed double-spaced pages.

Exercise 3: Future Trend: Psychologists as Gatekeepers for Physician-Assisted Suicide?

Suicide in the deliberate taking of one’s life, and most of us tend to think of suicide as the
least functional outcome of a human life. Mental health professionals go to great lengths to
prevent suicide and to alleviate the suffering that contributes to it. Physician-assisted suicide, by
contrast, is a case where medical professionals appear to be facilitating suicide in terminally ill
individuals, not acting to preventing it. Though psychologists have not assumed an active role in
assisting suicide directly, there is great debate about the role(s) psychologists ought to take in
such cases. It could be argued that psychologists, by virtue of their unique training and
assessment skills, are best positioned to serve as gatekeepers for physician-assisted suicide.
Given trends for prescription authority for psychologists, one may even wonder whether
psychologists may someday function as some physicians do now in assisting terminally ill
patients to take their own lives. This topic spans a range of ethical, moral, and legal issues that

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lend themselves to a debate format, or in-class discussion about suicide and the role of
psychologists in the prevention and alleviation of suffering. The links below provide some
additional information and resources on this topic.

http://www.apa.org/pi/aseol/introduction.html
http://www.apa.org/ppo/issues/asresolu.html
http://www.psychiatrictimes.com/p040101b.html
http://www.nrlc.org/euthanasia/asisuid1.html
Fenn, D. S., & Ganzini, L. (1999). Attitudes of Oregon psychologists toward physician-
assisted suicide and the Oregon Death With Dignity Act. Professional Psychology: Research
and Practice, 30, 235–244.

IDEAS FOR INSTRUCTION

1. Activity: Suicide Questionnaire. Give students HANDOUT 7.1 to enable them to test
their knowledge about suicide. After they have completed the handout, discuss the correct
answers with them and address concerns voiced by class members. Correct answers:
a. (F) Although there may be some people who talk about suicide but never follow
through, those who talk about suicide are at high risk for suicide. Many who
successfully kill themselves have made earlier threats to do so.
b. (F) Many people are suicidal for a short period of time; some who make it
through a suicidal crisis recover completely.
c. (F) Many people offer clues they are considering suicide before they attempt to
kill themselves. About 80% of suicide attempts are preceded by a warning of
some kind.
d. (F) Talking about suicide can be helpful in prevention and does not trigger the
act. In fact, you may show the person that you are not frightened and are willing
to talk about it with them.
e. (T) A depressed person who gives away valued possessions may be preparing for
suicide.
f. (F) A sudden recovery from depression is a clue the person is considering suicide
and has attained peace of mind as a consequence of their plan.

2. Activity: Suicide Prevention. You may want to give your students HANDOUT 7.2 on
suicide prevention. Discuss students' reactions to the suggestions and add any
recommendations that class members may have regarding helping someone who is
suicidal. You may also use the discussion as an opportunity to talk about assisted suicide.

3. Activity: A Self-Rating Depression Scale. A self-assessment inventory was developed

by Zung (1965) to measure both the feelings and physical factors associated with
depression (e.g., changes in eating and sleeping habits, lethargy, etc.). Though the clinical
utility and psychometric properties of this measure are questionable, the scale nicely
illustrates components of depression and takes only a few minutes to complete.

Source Information. Zung, W. (1965) A self-rating depression scale. Archives of

General Psychiatry, 12, 63-70.

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4. Activity: Bipolar Disorder Screening. You may want to also give your students
HANDOUT 7.3 that depicts items developed by the Depression and Bipolar Support
Alliance as a brief screening tool for bipolar disorder. The items give students a sense of
some of the problems associated with bipolar disorder.

Source Information. This screening tool was developed by the Depression and
Bipolar Support Alliance and is available on line at
http://www.dbsalliance.org/pdfs/MDQ.pdf.

5. Activity: Screening for Disorders in Primary Care. Break students into groups and
have them to imagine that they are in charge of implementing a screening program to
detect mood disorders and suicidality among patients in the clinic. Stress that because of
demands on physicians’ time, they must limit their screening questionnaire to five items.
Discuss how they selected the items they chose, as well as the difficulty of detecting
serious mood symptoms in the general population.

6. Video Activity: Abnormal Psychology, Inside/Out, Vol. 1. After reviewing the nature
of depressive disorders, present the video segment depicting Barbara, but do not let on
about her diagnosis. Ask students to see if they can arrive at a diagnosis for Barbara.
The correct answer is unipolar depression, without psychosis.

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COPYRIGHT (c) 2009 Wadsworth Group.
Wadsworth is an imprint of the Wadsworth Group, a division of Cengage Learning, Inc.

HANDOUT 7.1

WHAT DO YOU KNOW ABOUT SUICIDE?

Respond to each of the following questions by answering true or false:

1. _____ People who talk about suicide rarely follow through and actually attempt or
commit suicide.

2. _____ People who are suicidal will remain suicidal their entire lives.

3. _____ Almost all suicides take place with little or no warning.

4. _____ Talking about suicide often precipitates a desire to follow through and do it.

5. _____ Giving away valued possessions is a clue that a person may be considering
suicide.

6. _____ Someone who is recovering from severe depression and suddenly develops a
positive outlook on life rarely commits suicide.

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COPYRIGHT (c) 2009 Wadsworth a division of Cengage Learning, Inc.

HANDOUT 7.2

SUICIDE PREVENTION
Although there is no one best way to approach a situation where suicide may be a
possibility, the guidelines that follow may be helpful.

1. Treat the person as a normal human being.

2. Don't consider the person too vulnerable or fragile to talk about the possibility of suicide.
Raise the subject yourself by asking the person directly. For example, "It sounds like you
are feeling depressed. Have you been thinking about harming or hurting yourself or
committing suicide?"

3. Show the person you care about them even if you don't know them very well.

4. Help the person talk about and clarify the problem. Those who are depressed may have
difficulty pinpointing the problem and may feel frustrated and confused.

5. Listen carefully. People who are considering suicide are in mental and/or physical pain,
although you may not be able to guess the type of pain or the source of the problem. Be
there to help the person talk about the issue. You don't need to fix the problem.

6. Suicide is often viewed as the final solution to an overwhelming problem. The person
who is depressed may have difficulty sorting out alternative solutions to the problem(s)
he/she faces.

7. Encourage the person to seek professional assistance. Crisis hotlines are available in
many communities. If an immediate danger of suicide exists, do not leave the person
alone. If the crisis seems to be improved for the moment, be sure you have a plan of
action regarding professional help before leaving the person. Have the person promise to
call you before doing any harm to him/herself. Offer to accompany him/her to see a
mental health professional.

8. If a friend refuses help, you may need to contact someone close to him/her such as a
family member to share your concerns.

9. Maintain contact with your friend.

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COPYRIGHT (c) 2009 Wadsworth, a division of Cengage Learning, Inc.

HANDOUT 7.3
THE MOOD DISORDER QUESTIONNAIRE
Items in this questionnaire are intended as a screening instrument. Please answer each
question as best you can by circling either yes or no.

1. Has there ever been a period of time when you were not your usual self and...

Yes No ...you felt so good or so hyper that other people thought you were not your
normal self or you were so hyper that you got into trouble?
Yes No ...you were so irritable that you shouted at people or started fights or
arguments?
Yes No ...you felt much more self-confident than usual?
Yes No ...you got much less sleep than usual and found you didn't really miss it?
Yes No ...you were much more talkative or spoke much faster than usual?
Yes No ...thoughts raced through your head or you couldn't slow your mind down?
Yes No ...you were so easily distracted by things around you that you had trouble
concentrating or staying on track?
Yes No ...you had much more energy than usual?
Yes No ...you were much more active or did many more things than usual?
Yes No ...you were much more social or outgoing than usual, for example, you
telephoned friends in the middle of the night?
Yes No ...you were much more interested in sex than usual?
Yes No ...you did things that were unusual for you or that other people might have
thought were excessive, foolish, or risky?
Yes No ...spending money got you or your family into trouble?

2. If you checked YES to more than one of the above, have several of these ever happened during
the same period of time? Yes No

3. How much of a problem did any of these cause you -- like being unable to work; having
family, money or legal troubles, getting into arguments or fights? Please select one response only.

No Problem Minor Problem Moderate Problem Serious Problem

Source Information. This screening tool was developed by National Depressive and
Manic-Depressive Association and is available on line at http://www.ndmda.org/screening.asp.

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 SUPPLEMENTARY READING MATERIAL

:
A First -Person Account of Bipolar Disorder
An Unquiet Mind by Kay Redfield Jamison, copyright © 1995. Alfred A. Knopf, a
division of Random House, Inc.
In her gripping memoir, internationally respected authority on mood disorders author Kay
Jamison combines a scientist’s detachment with a novelist’s involvement in the dual
subject of herself and the bipolar disorder that is part of her. Her willingness to cast light
on every aspect of her experience results in passages that are chilling in their honesty.

InfoTrac Articles:

The following articles can be found on ―InfoTrac, the online library,” a resource available
through Wadsworth/Cengage Learning:

Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the
past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36,
1168(9).

Geller, B., Reising, D., Leonard, H., Riddle, M. A., & Walsh, B. T. (1999). Critical
review of tricyclic antidepressant use in children and adolescents. Journal of the
American Academy of Child and Adolescent Psychiatry, 38, 513(4).

Lewinsohn, P. M., Rohde, P., Seeley, J. R., & Baldwin, C. (2001). Gender differences
in suicide attempts from adolescence to young adulthood. Journal of the American
Academy of Child and Adolescent Psychiatry, 40, 427.

Additional Readings:
Beck, A. T. (1987). Cognitive therapy of depression. New York: Guilford.

Bernard, M. E., & DiGuiseppe, R. (Eds.) (1989). Inside rational-emotive therapy. New
York: Academic Press.

Burns, D. D. (1989). The feeling good handbook. New York: Plume.

Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and
therapy of depression. Philadelphia: Wiley.

Copeland, M. E. (1994). Living without depression and manic depression: A workbook

for maintaining mood stability. New York: New Harbinger.

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 Faedda, G., Tondo, L., & Ross, J. (1993). Seasonal mood disorders: Patterns of seasonal
recurrence in mania and depression. Archives of General Psychiatry, 50, 17-23.

Fremouw, W. J., Perczel, W. J., & Ellis, T. E. (1990). Suicide risk: Assessment and
response guidelines. New York: Pergamon.

Goodwin, F., & Jamison, K. (1990). Manic-depressive illness. New York: Oxford
University.

Gotlib, I. H. (1987). Treatment of depression: An interpersonal systems approach. New

York: Pergamon.

Styron, W. (1990). Darkness visible: A memoir of madness. New York: Vintage.

Thayer, R. E. (1996). The origin of everyday moods. New York: Oxford University.

Young, J. E., & Klosko, J. S. (1993). Reinventing your life: How to break free of negative
life patterns. New York: Dutton.

SUPPLEMENTARY VIDEO RESOURCES

Abnormal psychology, Inside/Out, Vol. 1. (Available through your International
Cengage Learning representative). This volume presents an interview with a patient named
Barbara, who is experiencing a major depressive episode. Barbara notes that she was depressed
most of her life, beginning in high school when she had a headache that lasted for one and one-
half years. She describes her current dissatisfaction with her appearance, sleep disturbances,
overeating while depressed, and problems with social withdrawal. Barbara was diagnosed with
unipolar depression, without psychosis. (11 min)
The second segment presents the case of Mary, who was diagnosed with bipolar
depression with psychotic symptoms. During the first interview Mary is experiencing a
depressive episode, whereas during the second interview she is in the midst of a manic episode.
(15 min)

Abnormal psychology, Inside/Out, Vol. 2. (Available through your International

Cengage Learning representative). A segment on this tape provides an overview of the
characteristics of MDD, including an interview with a female client who describes her
experience when she is in the midst of a major depressive episode. The female client also talks
about her decision to commit suicide. A related segment, titled ―Feeling Bad,‖ also covers the
feelings that accompany major depression, whereas the segment ―Feeling Better After
Treatment,‖ presents an interview with a female client that describes the stigma she experiences
with MDD, how her life improved with treatment, and the importance of asking for help. (7
min)

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 Antidepressant agents. (Insight Media: 2162 Broadway, New York, NY 10024/ (800)-
233-9910). This video examines the causes and manifestations of depression. It considers
neurotransmitters and receptors in the brain; presents theories related to how medication provides
relief from depression; and examines the three categories of antidepressant agents — tricyclic
agents, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors. (23 min)

Breaking the dark horse: A family copes with manic depression. (Fanlight Productions, 1-
800-937-4113). The video presents a story of a woman with manic depression and how it affects
her family and friends. (32 min)

CBT for depressed adolescents. (Insight Media: 2162 Broadway, New York, NY 10024/
(800)-233-9910). This three-part video presents cognitive behavioral intervention for
adolescents with depression. It reviews the theoretical basis for cognitive behavioral treatment
(CBT) and then provides illustrative vignettes. Finally, it discusses potential difficulties
encountered when using CBT with adolescents and their families. (130 min)

Demonstration of the cognitive therapy of depression. (Insight Media: 2162 Broadway,

New York, NY 10024/ (800)-233-9910). Aaron Beck, one of the major proponents of cognitive
theory and developer of the Beck Depression Inventory, demonstrates his method of cognitive
therapy of depression in this interview with a depressed and suicidal woman. The tape illustrates
how to conceptualize a patient in a cognitive framework. (40 min)

Depression and manic depression. (Insight Media: 2162 Broadway, New York, NY
10024/ (800)-233-9910). Explaining that many cases of clinical depression remain untreated due
to issues of stigma and fear, this video explores the relationship between untreated depression
and suicide, using as examples the depressions of such well-known public figures as Mike
Wallace and Kay Redfield Jamison. (28 min)

Four lives: A portrait of manic-depression. (Insight Media: 2162 Broadway, New York,
NY 10024/ (800)-233-9910). This video explores the psychological effects of bipolar affective
disorder by examining four patients. Psychiatrists discuss the history and treatment of each
patient, describing the rapid mood swings from depression to mania and considering common
manifestations of these moods. The program also examines the uses of ECT, lithium treatment,
and psychotherapy. (60 min)

Girl Interrupted. (Hollywood Film; Drama). This film, set in the 1960s, illustrates a
compelling true story of a woman who attempted suicide and subsequently self-committed to a
mental institution. The range of psychopathology of the characters, including the depiction of
treatment and life in a mental institution during the 1960s, is outstanding. This film nicely
illustrates depression, suicide, but may be useful for personality disorders, schizophrenia, and
ethical and legal issues as well.

It’s a Wonderful Life. (Hollywood Film; Drama). This film presents Jimmy Stewart who
responds to the stress of life in Bedford Falls by attempting suicide.

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 Life Upside Down. (Hollywood Film; Drama). French film about an ordinary young man
who becomes increasingly detached from the world. He is eventually hospitalized and treated,
but without much success.

Ordinary People. (Hollywood Film; Drama). This film deals with depression, suicide,
and family pathology and presents a sympathetic portrayal of a psychiatrist who probably meets
DSM-IV-TR criteria for PTSD and depression.

Psychopharmacology for the 21st Century: Antidepressants. (Insight Media: 2162

Broadway, New York, NY 10024/ (800)-233-9910). In this program, Joel Holiner provides an
in-depth overview of antidepressants, reviewing their efficacies, dosages, and side-effects. He
discusses uses of tricyclics, heterocyclics, lithium, and MAOIs for treating depression, anxiety,
social phobia, bulimia, and OCD. He also presents recommendations for antidepressant use
during pregnancy and highlights the advantages of the newest SSRIs, including Luvox and
Celexa, the latest SS -Norepinephrine reuptake inhibitor. (30 min)

The choice of a lifetime. (Fanlight Productions, 1-800-937-4113). This disturbing, but

ultimately inspiring, film is told from the point of view of six people, ages 21 to 73, who stepped
back from the brink of suicide. In candid interviews, they examine the circumstances that led to
their despair, the forces that stopped them, and the methods of healing they discovered, including
therapy, support groups, spirituality, and artistic expression. (53 min)

The depressed child. (Insight Media: 2162 Broadway, New York, NY 10024/ (800)-233-
9910). Seven percent of children and 27 percent of adolescents meet the criteria for major
depressive disorder. If left undiagnosed, depression can have negative long-term effects or lead
to suicide. This video examines the problem of youth depression and discusses such treatment
options as counseling and antidepressant medications. (25 min)

The Hospital. (Hollywood Film; Comedy/Drama). George C. Scott depicts a suicidal

physician.

The Mosquito Coast. (Hollywood Film; Adventure). Harrison Ford plays an eccentric
American inventor who flees the U.S. for Central America because of his paranoia. His behavior
throughout the film is bipolar, and certainly manic.

Treatment strategies for the management of chronic depression. (Insight Media: 2162
Broadway, New York, NY 10024/ (800)-233-9910). An estimated five percent of depression
victims suffer from lifelong, chronic depression. This program explores how outcomes may be
complicated by co-morbid psychiatric and medical conditions, as well as chronic stressors. It
discusses the diagnosis of chronic depression and presents management strategies and challenges
for the clinician. (90 min)

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 INTERNET RESOURCES

Bipolar Disorder
http://www.mentalhealth.com/dis/p20-md02.html
Internet Mental Health provides this informative web page; information on other
disorders is provided as well.

Cyclothymia
http://www.mentalhealth.com/dis/p20-md03.html
Internet Mental Health provides this informative web page; information on other
disorders is provided as well.

Depression and Bipolar Support Alliance

http://www.dbsalliance.org/
Provides a number of links and resources related to mood disorders.

Depression Central
http://www.psycom.net/depression.central.html
Dr. Ivan’s Depression Central offers links to several sites on mood disorders, including
sites for books, videos, research, diagnosis, and treatment.

Dysthymia
http://www.mentalhealth.com/dis/p20-md04.html
Internet Mental Health provides this informative web page; information on other
disorders is provided as well.

Facts about Women and Depression

http://www.nimh.nih.gov/HealthInformation/depwomen.cfm
An NIMH web page containing many facts regarding women and mental health.

Major Depressive Disorder

http://www.mentalhealth.com/dis/p20-md01.html
Internet Mental Health provides this informative web page; information on other
disorders is provided as well.

Online Depression Screening Test

http://www.med.nyu.edu/psych/screens/depres.html
The Department of Psychiatry at NYU Medical Center hosts this online screening tool for
symptoms of depression.

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Psychology Information Online
http://www.psychologyinfo.com/depression/index.html
A useful resource to information about the nature of mood disorders, including links to other
related sites.

Suicide Resources at the National Institute of Mental Health

http://www.nimh.nih.gov/SuicidePrevention/index.cfm
This NIMH site has several useful bits of information related to suicide and depression,
including information on the nature of suicide and data on its prevalence and incidence.

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WARNING SIGNS
OF DEPRESSION
The following signs and symptoms are considered indicators of depression if
they persist for a period of more than two weeks.

 Feeling sad or empty most of the day, nearly every day

 Reduced interest and pleasure in activities
 Significant unintentional weight loss or gain or a change in appetite
 Over or under sleeping
 Feeling worthless, hopeless, and/or inappropriately guilty
 Recurrent thoughts of death or suicide

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COPYRIGHT (c) 2009 Wadsworth, a division of Cengage Learning, Inc.

WARNING SIGNS
OF CHILDHOOD DEPRESSION
The following signs and symptoms are considered indicators of depression if
they persist for a period of more than two weeks.

 Persistent sadness and hopelessness

 Withdrawal from friends and activities once enjoyed
 Increased irritability or agitation
 Missed school or poor school performance
 Changes in eating and sleeping habits
 Indecision, lack of concentration, or forgetfulness
 Poor self-esteem or guilt
 Frequent physical complaints, such as headaches and stomachaches
 Lack of enthusiasm, low energy or motivation
 Drug and/or alcohol abuse
 Recurring thoughts of death or suicide

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WARNING SIGNS
OF BIPOLAR DISORDER
Increased Energy
 Decreased Sleep, Little Fatigue
 An Increase in Activities
 Restlessness

Speech Disruptions
 Rapid, Pressured Speech
 Incoherent Speech, Clang Associations

Impaired Judgment
 Lack of Insight
 Inappropriate Humor and Behaviors
 Impulsive Behaviors
 Financial Extravagance
 Grandiose Thinking

Increased or Decreased Sexuality

Changes in Thought Patterns

 Distractibility
 Creative Thinking
 Flight of Ideas
 Disorientation
 Disjointed Thinking
 Racing Thoughts

Changes in Mood
 Irritability
 Excitability
 Hostility
 Feelings of Exhilaration

Changes in Perceptions
 Inflated Self-Esteem
 Hallucinations
 Paranoia
 Increased Religious Activities

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WARNING SIGNS
OF MANIA AND HYPOMANIA
 Insomnia or difficulty sleeping
 Writing pressure
 Others seem slow
 Irritability or surges of energy
 Making lots of plans
 Flight of Ideas
 Pressured speech
 Poor judgment and/or inappropriate behavior
 Increased alcohol consumption
 Spending too much money
 Very productive
 Taking too many responsibilities
 Feeling superior
 Increased creativity
 Dangerous driving
 Unnecessary phone calls
 More sensitive than usual
 Increased appetite and sexual activity
 Noises louder than usual
 Doing several things at once
 Inability to concentrate
 Friends notice behavior change
 Difficulty staying still
 Sociable and thrill seeking
 Anxious and wound-up

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WARNING SIGNS
FOR SUICIDE (GENERAL)
 Verbal suicide threats or statements
 Previous suicide attempt
 Risk-taking behavior, reckless behavior
 Final arrangements -- giving away prized possessions, making peace, tying
up loose ends
 Neglect of academic work and/or personal appearance
 Separation from loved ones or significant others
 Themes in writing or art about death, depression, or suicide
 Talk of wanting to die
 Chronic depression; prolonged grief after a loss
 Unusual purchases -- gun, rope, medications; gathering of pills or poisons
 Unusual sadness, discouragement, and loneliness
 Unexpected happiness (sudden happiness following prolonged depression)
 Physical complaints, hyperactivity, substance abuse, aggressiveness

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 DSM-IV-TR TAB LES
The following DSM-IV-TR tables can be found in the main text on page number indicated.

Chapter 7 Mood Disorders and Suicide

DSM Table 7.1 Criteria for Major Depressive Episode ...........................................208
DSM Table 7.2 Criteria for Manic Episode ............................................................209
DSM Table 7.3 Diagnostic Criteria for Major Depressive Disorder,
Single Episode ..............................................................................210
DSM Table 7.4 Diagnostic Criteria for Dysthymic Disorder ...................................211
DSM Table 7.5 Diagnostic Criteria for Bipolar II Disorder .....................................216
DSM Table 7.6 Criteria for Cyclothymic Disorder .................................................217

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