(精神病學課件)mood-disorder-and-suicide

MoodDisordersandSuicideByYixiaoFuDepartmentofPsychiatryOutlineMooddisorders,depressionandmaniaDepressivedisordersBipolardisordersCausesofmooddisordersTreatmentofmooddisordersSuicideDepressivedisorderMAJORMooddisorders,depressionandmaniaMooddisordersGroupofdisordersinvolvingsevereandenduringdisturbancesinemotion(mood)(prevalenceinpopulationbetween8%and19%)MajordepressiveepisodeExtremelydepressedmoodstatethatlastsatleast2weeksandincludescognitivesymptoms(worthlessness,indecisiveness)andphysicalsymptoms(alteredsleepingpattern,changesinappetiteandweight,lossofenergy)ManiaEpisodeofjoyandeuphoriamarkedbyindividual’sextremepleasureineveryactivity,hyperactivity,littlesleepHypomanialesssevereversionofamanicepisodethatdoesnotcausemarkedimpairmentinsocialoroccupationalfunctioningDysphoricmanicormixedepisodetheindividualexperiencesbothelationanddepressionoranxietyatthesametimeMooddisorders,depressionandmaniaUnipolarmooddisorderIndividualsexperienceeitherdepressionormaniabutnotbothBipolarmooddisorderIndividualsalternatebetweendepressionandmaniaMooddisordersAdditionalstatistics32%ofchildrenwithADHDalsometcriteriaformajordepression18%to20%ofnursinghomeresidentsmayexperiencemajordepressiveepisodes20%ofagroupoffamousAmericanpoetsexhibitedbipolardisordersThereseemstobesignificantoverlapbetweenanxietyanddepressionwithrespecttocausesandoccurrenceDepressivedisorders

Majordepressivedisorder,singleepisodeInvolvesonlyonemajordepressiveepisodeinlifetime(veryrare–85%ofsingleepisodesarefollowedbyrepeatedepisodes)(12%suicidalattempts)Majordepressivedisorder,recurrentY-BarbaraInvolvesrepeatedmajordepressiveepisodesseparatedbyaperiodofatleast2monthsduringwhichtheindividualwasnotdepressedDysthymicdisorderthesamesymptomsasmajordepressivedisorderbutpresentedinmilderform,thedepressedmoodcontinuesforatleast2yearsDoubledepressionCombinationofmajordepressionepisodesanddysthymicdisorderDepressivedisorders

Usualonsetis25yearsbutisdecreasingDepressiveepisodeslastfrom2weeksuptoyearsAdultpatientswithdysthymicdisorderaremorelikelytocommitsuicidethanpatientswithmajordepressivedisorderDepressioncanresultfromgriefPathologicalgriefreactioninvolvespsychoticfeatures,suicidalideation,severelossofweightorenergythatpersistsmorethan2monthsTherapyinvolvesreexperiencingthetraumaundersupervisionandfindingmeaninginthelossBipolardisorders

BipolarIdisorderY-MaryDepressiveepisodesalternatewithfullmanicepisodes(17%suicidalattempts)(onsetatage18)BipolarIIdisorderDepressiveepisodesalternatewithhypomanicepisodes(24%suicidalattempts)(onsetatage22)CyclothymicdisorderChronicalternationofmoodelevati+onanddepressionthatdoesnotreachtheseverityofmanicormajordepressiveepisodesSeasonalaffectivedisorder(SAD)Mooddisorderinvolvingacyclingofepisodescorrespondingtotheseasonsoftheyear,typicallywithdepressionoccurringinthewinter(10%inNewHampshireand2%inFlorida)Causesofmooddisorders

biologicalfactorsifonetwinpresentswithamooddisorder,anidenticaltwinisapproximatelythreetimesmorelikelythanafraternaltwintohaveamooddisorder(heritabilityapprox.40%forwomen)psychologicalfactorsstressfullifeevents,hopelessness,negativecognitivestyles-overgeneralizationsocialandculturalfactorsmaritaldissatisfaction70%ofpeoplesufferingwithmajordepressivedisorderordysthymiaarewomenCausesofmooddisorders

TreatmentofmooddisordersMedicationsAntidepressants(numberofsideeffects)Monoamineoxidase(MAO)inhibitors(negativeinteractionswithtyramine)Selectiveserotonergicreuptakeinhibitors(SSRIs)(sideeffects)Lithium(weightgain,dangerofpoisoning)Electroconvulsivetherapy(ECT)andtranscranialmagneticstimulation(TMS)asanalternativetoECTPsychosocialtreatmentsCognitivetherapyInterpersonaltherapyCombinedtreatmentsV-Bipolarindepression(medicationandpsychosocialtreatments)inbipolardisorders(combiningmedicationandfamilyand/orCBTiscrucial)Suicide8thleadingcauseofdeathintheUSA(30000peopleayear)forpeopleaged25-34Amongteenagers,suicideisthe3rd

leadingcauseofdeathThesuiciderateforyoungmenintheUSAisthehighestintheworldMalesarefourtofivetimesmorelikelytocommitsuicidethanfemales90%ofsuicidesarecommittedbypeoplesufferingfrompsychologicaldisorder60%areassociatedwithmooddisorders25%-50%withalcoholuseandabuse10%borderlinepersonalitydisorderSuicideSuicidalattemptSuicidalideationTypesofsuicide(‘formalized’suicide–altruisticsuicide,egoisticsuicide,fatalisticsuicideetc.)Psychologicalautopsy(postmortempsychologicalprofileofasuicidevictim)Imitationofsuicide(teenagerorcelebrity)Suicidepreventioncognitive-behavioralproblem-solvingapproachstrongsocialsupportandhopefulnesstreatmentofpsychiatricandpersonalitydisordersMAJORDEPRESSIVEDISORDEROneThinginCommon--DepressionGreatwriterHemingway

ScientistDarwinArtistvangoghPrimeMinisterChurchillSuperstar

MarilynMonroeDepressionisCommonTheWHOidentifieddepressionasthefourthleadingcauseofworldwidediseasein1990,anddepressiveillnessisprojectedtobethesecondleadingcauseofdisabilityworldwidein2020.

MurrayCJ,LopezAD.Theglobalburdenofdisease:acomprehensiveassessmentofmortalityanddisabilityfromdiseases,injuries,andriskfactorsin1990andprojectedto2020.Cambridge,Mass.:HarvardUniversityPress,1996.

Depressionisanillnessinvolvesthebody,mood,andthoughts.Itaffectsthewayapersoneatsandsleeps,thewayonefeelsaboutoneself,andthewayonethinksaboutthings.Itisnotthesameasunhappinessandisnotastatepeoplecan‘snapoutof’.Whatisdepression?DEPRESSION(DSM-IV-TR):MajorDepressiveDisorderDiagnosticandStatisticalManualofMentalDisorders

By:AmericanPsychiatricAssociation

(ICD-10):DepressiveEpisodeInternationalStatisticalClassificationofDiseasesandRelatedHealthProblemsBy:

WorldHealthOrganizationDepression(informal)Scholarfield:Diagnosticcriteria:MDD/DEPRESSION1Epidemiology(who)2Etiology3Clinical

Feature4Diagnose5Management1Epidemiology（who）2Etiology（why）3Clinical

Feature（what）4Diagnose（whatisMDD）5Management（how）EpidemiologyThelifetimeriskisabout15%Outofvery100peopleabout13menand21womendevelopthedisorder（MDDoccursmoreonwoman)TeenagersaremostlikelytodevelopMDDduetodevelopingthesymptomsofsadness,loneliness,stress.Upto15%ofpeoplewithMDDdiebysuicide1Epidemiology2Etiology(why)3Clinical

Feature4Diagnose5Management25geneticpredispositionFamilyandTwinstudiesshowthatMDDhasadefinitegeneticcomponent.theriskrateamongfirst-degreerelativesofindividualssufferingfromMDDisabouttwotothreetimestheriskinthegeneralpopulation.Thereisahigherconcordancerate(about40%)inmonozygoticcomparedwithdizygotic(about11%）twins.Nosinglemajorgenehasyetbeenshowntobeinvolved(polygenicinheritance).Geneshavenotyettobeidentified Etiology26SocialandEnvironmentalInfluenceshistoricalfactors:

earlymaternaldeath,parentalneglect,alongperiodofseparationfromaparentduringchildhood,childhoodsexualabuse

experiences—personalitycurrentfactors（stress）

unemployment,DisappointedInLove…….（‘loss’lifeevents）

Etiology27Biochemicalfactors

NeurotransmitterEtiology5-HTDANAACHEtiology;Bio-Psycho-Social29………….Etiology1Epidemiology2Etiology3Clinical

Feature(what)4Diagnose5ManagementofMDD?WhatarethesymptomsDSM-IV-TR1DEPRESSEDMOOD(SAD.HOPELESS)2FATIGUE,ENERGYLOSS3THOUGHTSOFDEATH/SUICIDE4DIFFICULTY5LACKOFINTEREST6INSOMNIA(WAKINGUPINTHEMIDDLEOFTHENIGHT/NOTBEINGABLETOGOBACKTOSLEEP))7RETARDATION8UNINTENTIONALWIGHTLOSS/APPETITTEDECREASEORINCREASE9DISTRESS/IMPAIRMENTClinicalFeatureBiologicalsymptomsCognitivesymptomsMoodandmotivationsymptomsMoodandmotivationsymptoms(corefeature)

1.Moodsymptoms

Sadness,anhedonia,unhappinessirritabilityAnxietysymptoms,panicattacks

ClinicalFeatureMoodandmotivationsymptoms(cordfeature)2.motivationsymptomslossofinterest,lowenergyandsocialwithdrawal(keepthemselvesintheroom,low-esteem,havenoconfidence)

ClinicalFeatureBiologicalsymptomslossofappetiteandweightlossofsexdrive(libido)Sleepdisturbancemostdays:eitherinitialinsomniaorearlymorningwakingandbeingunabletogetbacktosleep.Diurnalvariationofmood,suchthatmoodisworseinthemorningandslowlyliftsintheevening.non-specificphysicalsymptoms,suchastensionheadache,backpainandatypicalchestPsychomotorretardation(muteand‘stupor’)ClinicalFeatureBiologicalsymptomsLossofappetiteandweightLossofsexdriveBiologicalsymptomsEarlymorningwakingBiologicalsymptomsDiurnalvariationofmood123456789101112131415161718192021222324BiologicalsymptomsNon-specificphysicalsymptomsBiologicalsymptomsPsychomotorsymptomsCognitivesymptomsnegativethoughtsTothe

past(guilt,regretsandself-blame)Tothepresent(lowself-esteem,worthlessness)Tothefuture(pessimism,hopelessness,thoughtsofdyingandsuicidalideas)PsychoticdepressionDelusions(persecutory,hypochondriacal,guilt)

hallucinations(Auditory)

ClinicalFeatureSuicideDEPRESSIONOccasionalsadnessMentalillness1Epidemiology2Etiology3Clinical

Feature4Diagnose5ManagementDiagnoseDiagnoseCriteriaforMajordepressiveEpisode(DSM-Ⅳ)

itincludesfouraspects:

symptomcriteria,coursecriteriaseveritycriteriaexclusion.thesesymptomsmustpersistcontinuouslyforatleast2weeks.

Symptomscauseclinicallyimpairmentinsocial,occupational,orotherimportantareasoffunctioningSymptomsareNOTduetotheeffectsofasubstance(e.g.,drugofabuse,ormedication)orageneralmedicalcondition(e.g.,hyperthyroidism)5ormoreofthetotal9symptomsmustbemet.atleast1ofthosemustbeeitherdepressedmoodorlossofinterestorpleasure.1Epidemiology2Etiology3Clinical

Feature4Diagnose5ManagementManagement1.Preparation2.Treament

Ⅰ.Pharmacotherapy

Ⅱ.Electroconvulsivetherapy

1.PreparationHistory-takingwillincludealcoholanddruguseandpsychosocialhistorywithevidenceforsupportiverelationships.Suicidalriskassessmentisimportant.Physicalinvestigationswillincludeeosinophilsedimentationrate(ESR)andthyroidfunctionand,inolderpatients,chestXrayandcomputedtomographic(CT)scan.Management2.TreamentⅠ.PharmacotherapyA.Majordepre