Social and Psychological Bases of Depression and Suicide

Question 1

How many people worldwide suffer from depression ?

Answer 1

300 Million

Question 2

Identify some main consequences of depression.

Answer 2

1) PERSONAL
- Great distress and suffering

2) SOCIAL
- Disrupted relationships

3) ECONOMIC
- Prevents people from working (e.g. job loss, absenteeism)

Question 3

Define unipolar depression.

Answer 3

“a type that is not accompanied by episodes of mania or hypomania, such as major depressive disorder or dysthymic disorder. The term is sometimes used more specifically as a synonym of major depressive disorder”

Question 4

Define subthreshold depressive symptoms.

Answer 4

Symptoms which fall below the criteria for major depression, and are defined as at least one key symptom of depression but with insufficient other symptoms and/or functional impairment to meet the criteria for full diagnosis.

AKA

Dysthymia, depressive symptoms that are subthreshold for depression but lasts at least 2 years.

Question 5

Define bipolar disorder.

Answer 5

Manic-depressive illness. Characterised by severe highs (mania) and lows (depression).

Question 6

Identify examples of affective disorders.

Answer 6

Major depression

Subthreshold depressive symptoms (AKA Dysthymia)

Bipolar Disorder

Question 7

Identify the main features of major depression.

Answer 7

Loss of interest and enjoyment in ordinary things and experiences and low energy

Emotional, cognitive, physical, and behavioural symptoms

Low/Depressed mood

Question 8

Identify a tool for the assessment of depression.

Answer 8

Assessment of depression is based on the criteria in DSM-IV. Assessment should include the number and severity of symptoms, duration of the current episode, and course of illness (also take into account degree of functional impairment and/or disability associated with the possible depression, and also ask about past and family history of mood disorders, and availability of social support)
• Principles for assessment: biopsychosocial

Question 9

Identify key symptoms of depression.

Answer 9

Key symptoms:
• persistent sadness or low mood, unresponsive to circumstances (emotional)
• marked loss of interests or pleasure (in hobbies and activities that were once enjoyed) AKA ANHEDONIA (emotional)
➡At least one of these, most days, most of the time for at least 2 weeks.

If any of above present, ask about associated symptoms:
EMOTIONAL
• Irritability, tearfulness

BIOLOGICAL/BEHAVIORAL
• disturbed sleep (decreased or increased compared to usual)
• decreased or increased appetite and/or weight
• fatigue or loss of energy, or agitation
• Social withdrawal
• Loss of libido

COGNITIVE
• Negative view of the self, including:
-lowered self-esteem and self-confidence
-feelings of worthlessness or excessive or inappropriate guilt
-feelings of hopelessness and helplessness
-pessimistic and recurrently negatives thoughts about oneself, world, and future (negative cognitive triad)
• Mental slowing or rumination
• poor concentration or indecisiveness
• suicidal thoughts or acts

Question 10

Identify the categories of people with a higher risk of depression.

Answer 10

People with a past history of depression or a chronic physical health problem with associated functional impairment

Question 11

Identify questions to ask people who may have depression.

Answer 11

1) During the last month, have you often been bothered by feeling down, depressed or hopeless?
2) During the last month, have you often been bothered by having little interest or pleasure in doing things?

Question 12

Identify risk factors for depression.

Answer 12

1) Genetic and family factors
- Family history of major depression (suggested by twin studies)
- Genetic factors influence overall risk of illness BUT also influence the sensitivity of individuals to the depressogenic effects of environmental adversity (gene-environment interaction, genes on their own do NOT cause depression)

2) Early life experiences
-Poor parent-child relationship
-Marital discord and divorce
-Neglect (especially parental)
-Physical abuse (esp. from a core tie) and sexual abuse (irrespective of any parental loss)
-Early childhood loss (early loss of motion somewhat increased risk of neglect and abuse)
(-Feelings of humiliation and entrapment)

3) Stressful life events (most depressions are preceded by a recent stressful event. Such events can influence the onset and course of depression):
– Failure at work, at school, loss of a job;
– Marital separation;
– Rejection by a loved one;
– Death of a child;
– Illness of a family member;
– Physical illness

4) Social Support
- availability of good-quality support from friends and family offers protection to the individual in dealing with stressors which may otherwise precipitate a depressive episode
- lack of intimate or confiding relationship can increase the risk of depression.

5) Gender
-Seems to be more common in woman (2:1 ratio), due to many factors:
∙ Women may express and report symptoms more than men
∙ Hormones
∙ Early life stress: e.g., sexual abuse (girls are more likely to be sexually abused)
∙ Additional stresses such as responsibilities both at home and work, single parenthood, caring for children and aging parents

Question 13

Explain the relationship between depression and chronic illness.

Answer 13

• CHRONIC PHYSICAL CAN CAUSE, and EXACERBATE DEPRESSION
Although people with chronic illness generally function well psychologically, there is a significant minority who might be at risk for depression, especially through the pain, functional impairment and disability associated with chronic physical illness.

Examples: Documented for stroke, cancer, heart, HIV patients

Stats: (2-3x more common in chronic physical health patients. About 20% of chronic physical health patients have depression)

• DEPRESSION CAN EXACERBATE PAIN AND DISTRESS OF CHRONIC PHYSICAL ILLNESS AND ADVERSELY AFFECT OUTCOMES (AND INCREASE FUNCTIONAL IMPAIRMENT)
Including shortening life expectancy

• DEPRESSION CAN BE A RISK FACTOR IN DEVELOPMENT/WORSENING OF PHYSICAL ILLNESSES
Through:
– Adapting unhealthy behaviours (e.g., smoking, bad diet, lack exercise, poorer sleep, alcohol and substance abuse)
– Not adhering to medical regimens
– Direct effects on physiological mechanisms

Example: CV disease

Question 14

Why can assessment of depression in chronically ill patients can be problematic ?

Answer 14

-Many signs of depression, such as fatigue, insomnia, or weight loss may also be an expression of the disease itself
– Drug treatments can also cause depression as a side effect, especially hypertensives, corticostreoids, and chemotherapy agents

Question 15

Explain the relationship between depression and coronary heart disease (CHD).

Answer 15

DEPRESSION ➡ CHD
• Depression may contribute CHD by triggering dysregulation of neurohormonal systems responsible for cortisol and catecholamine secretion, and by resulting in inflammation and heart rate variability

• Major depression is associated with 2- to 4- fold increased risk for cardiac mortality among patients hospitalised for MI
• Depressed people without cardiac disease also have a significantly increased risk of cardiac mortality

• Depressed CHD patients are less likely to adhere to: – cardiac medication regimens
– Lifestyle risk factor interventions
– Cardiac rehabilitation programmes

• Depression may promote maladaptive health practices such as smoking

CHD ➡ Depression
• CHD may in turn cause/exacerbate depression through its manifestations (symptom burden, emotional distress, functional limitation)

Question 16

Describe treatment of depression.

Answer 16

1) Pharmacological treatments
2) Psychological treatments
- CBT (short term psychological treatment, emphasizes the role of thinking in how we feel and what we do, encourages identifying and challenging unhealthy modes of thinking that cause depressed feelings and behaviour)
- Mindfulness-based cognitive therapy (for people who are currently well but have experienced three or more previous episodes of depression)

3) Physical activity (mild and moderate depression or persistent subthreshold depressive symptoms)
4) Electroconvulsive treatment (for severe and complex depression)

Question 17

Identify the main NICE guideline for depression.

Answer 17

NICE CG90

Question 18

Describe typical treatment for people with persistent subthreshold depressive symptoms or mild to moderate depression.

Answer 18

For people with persistent subthreshold depressive symptoms or mild to moderate depression, consider offering one or more of the following interventions, guided by the person’s preference:

– individual guided self-help based on the principles of cognitive behavioural therapy (CBT)
– computerised cognitive behavioural therapy (CCBT)
– a structured group physical activity programme

Question 19

Describe typical prevention for people with depression who are considered to be at significant risk of relapse or who have residual symptoms.

Answer 19

People with depression who are considered to be at significant risk of relapse or who have residual symptoms, should be offered one of the following psychological interventions:

• individual CBT:
– for people who have relapsed despite antidepressant medication
– for people with a significant history of depression and residual symptoms
despite treatment

• Mindfulness-based Cognitive Therapy:
– for people who are currently well but have experienced three or more previous episodes of depression

Question 20

What is the ratio of men to women who commit suicide ?

Answer 20

In high income countries, 3 times as many men die of suicide than women do, but in low- and middle-income countries, the ratio is at 1.5 men to each woman.

Question 21

What age group is most at risk of suicide ?

Answer 21

Suicide rates are highest among aged 70 or older (men and women and worldwide)

Question 22

How does suicide rank as a cause of death among 15-29 year olds ?

Answer 22

Second

Question 23

Highest age range for suicide rate for men in the UK ?

Answer 23

45 to 49 years old

Question 24

Identify the main risk factors for suicide.

Answer 24

1) Health System
• Health care access, access to means to suicide, media reporting
• Stigma against seeking help for suicidal beh/mental health issues/substance abuse

2) Community/Relationships
• War/disaster;
• discrimination; isolation; abuse/violence

3) Individual Factors
• Previous suicide attempts
• Mental disorders
• Harmful use of alcohol
• Financial loss
• Chronic pain
• Family hx of suicide

Question 25

Identify examples of phrases to avoid in the context of suicide.

Answer 25

Commit suicide
Cry for Help 
Successful or unsuccessful suicide attempt 
Suicide victim
Suicide-prone
Suicide-tourist

Question 26

Identify examples of phrases to use in the context of suicide.

Answer 26

Take one's own life
Person at risk of suicide
Die by suicide
Suicide attempt
Completed suicide

Question 27

Identify examples of myths about suicide.

Answer 27

• It is not true that people who talk of suicide do not do it.
• It is not true that talking openly about the topic of suicide puts ‘the idea in their head’

Question 28

Describe NICE guidelines for addressing a person with risk of suicide.

Answer 28

Always ask people with depression directly about suicidal ideation and intent. If there is a risk of self- harm or suicide:
• assess whether the person has adequate social support and is aware of sources of help
• arrange help appropriate to the level of risk
• advise the person to seek further help if the situation deteriorates.

(also, address motivation for suicide and develop alternatives to suicide)

Question 29

Identify conversation starters for people with risk of suicide.

Answer 29

How are ? (if answer fine, then how are you really ?)
You don’t seem yourself
I’ve had a terrible week, how was yours ?
Is everything okay at home/work/uni ?

Question 30

Identify the steps to take if a patient is assessed to be at a suicidal risk.

Answer 30

– Additional support such as more frequent direct contacts with primary care staff or telephone contacts are particularly useful (e.g., setting up appointments)
– Inquire about social support and awareness of sources of help
– Referral to specialists