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Somatoform and Dissociative Disorders : 1 91

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1. What are the symptoms of each of the hysterical somatoform disorders? How do practitioners distinguish hysterical disorders from "genuine" medical problems? pp. 164-167

2. How does a somatoform disorder differ from a factitious disorder? pp. 167- 169

3. List the central features of each of the preoccupation somatoform disorders. pp. 169-170

..,,,..

4. What are the leading explanations and treatments for the somatoform disorders? How well does research support them? pp. 170- 176

5. List and describe the different dis- sociative disorders. pp. 176-184

6. What are four kinds of dissociative amnesia? pp. 177-780

7. What are the different kinds of rela- tionships that the subpersonalities may have in dissociative identity disorder? pp. 182-183

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8. Describe the psychodynamic, behavioral, state-dependent learn- ing, and self-hypnosis explanations of dissociative disorders. How well is each supported by research? pp. 184- 187

9. What approaches have been used to treat dissociative amnesia and dissociative fugue? pp. 187- 188

10. What are the key features of treatment for dissociative identity disorder? Is treatment successful? pp. 188-189

Search the Fundamentals of Abnormal Psychology Video Tool Kit www.worthpublishers.com/apvtk

A Chapter 6 Video Cases Beyond Perfection: Body Dysmorphic Disorder Repressed Memories or False Memories? Three Faces of Eve: The Real Patient

A Video case discussions, study guides, and questions

Log on to the Corner Web Page www.worthpublishers.com/comer

A Chapter 6 outline, learning objectives, research exercises, study tools, and practice test questions

A Additional Chapter 6 case studies, Web links, and FAQs

Somatoform and Dissociative Disorders : 1 91

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1. What are the symptoms of each of the hysterical somatoform disorders? How do practitioners distinguish hysterical disorders from "genuine" medical problems? pp. 164-167

2. How does a somatoform disorder differ from a factitious disorder? pp. 167- 169

3. List the central features of each of the preoccupation somatoform disorders. pp. 169-170

..,,,..

4. What are the leading explanations and treatments for the somatoform disorders? How well does research support them? pp. 170- 176

5. List and describe the different dis- sociative disorders. pp. 176-184

6. What are four kinds of dissociative amnesia? pp. 177-780

7. What are the different kinds of rela- tionships that the subpersonalities may have in dissociative identity disorder? pp. 182-183

• #!,,A 8' 0'1.5, 4, 4, {",$'47.

8. Describe the psychodynamic, behavioral, state-dependent learn- ing, and self-hypnosis explanations of dissociative disorders. How well is each supported by research? pp. 184- 187

9. What approaches have been used to treat dissociative amnesia and dissociative fugue? pp. 187- 188

10. What are the key features of treatment for dissociative identity disorder? Is treatment successful? pp. 188-189

Search the Fundamentals of Abnormal Psychology Video Tool Kit www.worthpublishers.com/apvtk

A Chapter 6 Video Cases Beyond Perfection: Body Dysmorphic Disorder Repressed Memories or False Memories? Three Faces of Eve: The Real Patient

A Video case discussions, study guides, and questions

Log on to the Corner Web Page www.worthpublishers.com/comer

A Chapter 6 outline, learning objectives, research exercises, study tools, and practice test questions

A Additional Chapter 6 case studies, Web links, and FAQs

MOOD DISORDERS

or ... a six-month period, her irritability bordered on the irrational. She screamed in anger or sobbed in despair at every dirty dish left on the coffee table or on the bedroom floor. Each day the need to plan the dinner menu provoked agonizing indecision. How

L: could all the virtues or, more likely, vices of hamburgers be accurately compared to those of spaghetti? . . . She hod her whole family walking on eggs. She thought they would be better off if she were dead.

Beatrice could not cope with her job. As a branch manager of a large chain store, she had many decisions to make. Unable to make them herself, she would ask employees who were much less competent for advice, but then she could not decide whose advice to take. Each morning before going to work, she complained of nausea. . . .

Beatrice's husband loved her, but he did not understand what was wrong. He thought that she would improve if he made her life easier by taking over more housework, cooking, and child care. His attempt to help only made Beatrice feel more guilty and worthless. She wanted to make a contribution to her family. She wanted to do the chores "like normal people" did but broke down crying at the smallest impediment to a perfect job. . . . Months passed, and Bea- trice's problem became more serious. Some days she was too upset to go to work. She stopped seeing her friends. She spent most of her time at home either yelling or crying. Finally, Beatrice's husband called the psychiatrist and insisted that something was seriously wrong.

Lickey & Gordon, 1991, p. 181

Most people's moods come and go. Their feelings of elation or sadness are under- standable reactions to daily events and do not affect their lives greatly.The moods of people with mood disorders, in contrast, tend to last a long time.As in Beatrice's case, the mood colors all of their interactions with the world and interferes with normal functioning.

Depression and mania are the key emotions in mood disorders. Depression is a low, sad state in which life seems dark and its challenges overwhelming. Mania, the opposite of depression, is a state of breathless euphoria, or at least frenzied energy, in which people may have an exaggerated belief that the world is theirs for the taking. Most people with a mood disorder suffer only from depression, a pattern called unipolar depression. They have no history of mania and return to a normal or nearly normal mood when their depression lifts. Others experi- ence periods of mania that alternate with periods of depression, a pattern called bipolar disorder.

Mood disorders have always captured people's interest, in part because so many famous people have suffered from them.The Bible speaks of the severe depressions of Nebuchadnezzar, Saul, and Moses. Queen Victoria of England and Abraham Lincoln seem to have experienced recurring depressions. Mood disorders also have plagued such writers as Ernest Hemingway, Eugene O'Neill,Virginia Woolf, and Sylvia Plath. Their severe mood problems have been shared by millions.

TOPIC OVERVIEW Unipolar Depression

How Common Is Unipolar Depression?

What Are the Symptoms of Depression?

Diagnosing Unipolar Depression

Stress and Unipolar Depression

The Biological Model of Unipolar Depression

Psychological Models of Unipolar Depression

The Sociocultural Model of Unipolar Depression

Bipolar Disorders What Are the Symptoms of Mania?

Diagnosing Bipolar Disorders

What Causes Bipolar Disorders?

What Are the Treatments for Bipolar Disorders?

Putting It Together: Making Sense of All That Is Known

MOOD DISORDERS

Lickey & Gordon, 1991, p. 181

TOPIC OVERVIEW Unipolar Depression

How Common Is Unipolar Depression?

What Are the Symptoms of Depression?

Diagnosing Unipolar Depression

Stress and Unipolar Depression

The Biological Model of Unipolar Depression

Psychological Models of Unipolar Depression

The Sociocultural Model of Unipolar Depression

Bipolar Disorders What Are the Symptoms of Mania?

Diagnosing Bipolar Disorders

What Causes Bipolar Disorders?

What Are the Treatments for Bipolar Disorders?

Putting It Together: Making Sense of All That Is Known

1 94 ://CHAPTER 7

,,Unipogar Depression Whenever we feel particularly unhappy, we are likely to describe ourselves as "depressed." In all likelihood, we are merely responding to sad events, fatigue, or unhappy thoughts.This loose use of the term confuses a perfectly normal mood swing with a clinical syndrome. All of us experience dejection from time to time, but only some experience unipolar depression. Clinical depression brings severe and long-lasting psychological pain that may intensify as time goes by. Those who suffer from it may lose their will to carry out the simplest of life's activities; some even lose their will to live.

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edepressioneA low, sad state marked by lack of energy, low self-worth, guilt, or related symptoms.

emaniacA state or episode of euphoria or frenzied activity in which people may have an exaggerated belief that the world is theirs for the taking.

ounipolar depression*Depression without a history of mania.

ebipolar disorder°A disorder marked by alternating or intermixed periods of mania and depression.

How Common Is Unipolar Depression? Almost 7 percent of adults in the United States suffer from a severe unipolar pat- tern of depression in any given year, while as many as 5 percent suffer from mild forms (Kessler & Wang, 2009; Taube-Schiff & Lau, 2008). Around 17 percent of all adults experience an episode of severe unipolar depression at some point in their lives. These prevalence rates are similar in Canada, England, France, and many other countries (Vasiliadis et al., 2007; WHO, 2004).

In almost all countries, women are at least twice as likely as men to experi- ence episodes of severe unipolar depression (Taube-Schiff & Lau, 2008). As many as 26 percent of women may have an episode at some time in their lives, compared with 12 percent of men. Among children the prevalence is similar for girls and boys (Avenevoli et al., 2008). All of these rates hold steady across the various socioeconomic classes and ethnic groups.

Approximately half of the people with unipolar depression recover within six weeks and 90 percent recover within a year, some without treatment

(Kessler, 2002; Kendler et al., 1997). However, most of them have at least one other episode of depression later in their lives (Taube-Schiff & Lau, 2008).

What Are the Symptoms of Depression? The picture of depression may vary from person to person. Earlier you saw how Beatrice's indecisiveness, uncontrollable sobbing, and feelings of despair, anger, and worthlessness brought her job and social life to a standstill. Other depressed people have symptoms that are less severe. They manage to function, although their depression typically robs them of much effectiveness or pleasure, as you can see in the case of Derek:

Derek has probably suffered from depression all of his adult life but was unaware of it for many years. Derek called himself a night person, claiming that he could not think clearly until after noon even though he was often awake by 4:00 A.M. He tried to schedule his work as editorial writer for a small town newspaper so that it was compatible with his de- pressed mood at the beginning of the day. Therefore, he scheduled meetings for the morn- ings; talking with people got him moving. He saved writing and decision making for later in the day.

.. Derek's private thoughts were rarely cheerful and self-confident. He felt that his marriage was a mere business partnership. He provided the money, and she provided a home and children. Derek and his wife rarely expressed affection for each other. Occasion- ally, he had images of his own violent death in a bicycle crash, in a plane crash, or in a murder by an unidentified assailant.

Derek felt that he was constantly on the edge of job failure. He was disappointed that his editorials had not attracted the attention of larger papers. He was certain that several of the younger people on the paper had better ideas and wrote more skillfully than he did. He scolded himself fora bad editorial that he had written ten years earlier. Although that particular piece had not been up to his usual standards, everyone else on the paper

1 94 ://CHAPTER 7

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edepressioneA low, sad state marked by lack of energy, low self-worth, guilt, or related symptoms.

emaniacA state or episode of euphoria or frenzied activity in which people may have an exaggerated belief that the world is theirs for the taking.

ounipolar depression*Depression without a history of mania.

ebipolar disorder°A disorder marked by alternating or intermixed periods of mania and depression.

Approximately half of the people with unipolar depression recover within six weeks and 90 percent recover within a year, some without treatment

(Kessler, 2002; Kendler et al., 1997). However, most of them have at least one other episode of depression later in their lives (Taube-Schiff & Lau, 2008).

he Color of Depression

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LOW SELF-ESTEEM

Mood Disorders :11 195

had forgotten it a week after it appeared. But ten years later, Derek was still ruminating over that one editorial. . . .

Derek brushed off his morning confusion as a lack of quick intelligence. He had no way to know that it was a symptom of depression. He never realized that his death images might be suicidal thinking. People do not talk about such things. For all Derek knew, everyone had similar thoughts.

(Lithe) , & Gordon, 1991, pp. 183-185)

MP.

As the cases of Beatrice and Derek indicate, depression has many symptoms other than sadness. The symptoms, which often feed upon one another, span five areas of functioning: emotional, motivational, behavioral, cognitive, and physical.

Emotion El Symptoms Most people who are depressed feel sad and dejected.They describe themselves as feeling "miserable," "empty," and "humiliated." They tend to lose their sense o I humor, report getting little pleasure from anything, and in some cases dis- play anlredonia, an inability to experience any pleasure at all. A number also experience anxiety; ange r, or agitation.This sea of misery may lead to crying spells.

MOtiVatiOnal Symptoms Depressed people typically lose the desire to pursue their usual activities. Almost all report a lack of drive, initiative, and spontaneity. They may have to force themselves to go to work, talk with friends, eat meals, or have sex. Terrie Williams, author of Black Pain, a book about depression in African Americans, describes her social withdrawal during a depressive episode:

I woke up one morning with a knot of fear in my stomach so crippling that I couldn't face light, much less day, and so intense that I stayed in bed for three days with the shades drawn and the lights out.

Three days. Three days not answering the phone. Three days not checking my e-mail. I was disconnected completely from the outside world, and I didn't care. Then on the morn- ing of the fourth day there was a knock on my door. Since I hadn't ordered food I ignored it. The knocking kept up and I kept ignoring it. 1 heard the sound of keys rattling in my front door. Slowly the bedroom door opened and in the painful light from the doorway I saw the figures of two old friends. "Terrie, are you in there?"

(Williams, 2008, p. xxiv)

Suicide represents the ultimate escape from life's challenges.As you will see in Chapter 8, many depressed people become uninterested in life or wish to die; others wish they could kill themselves, and some actually do. It has been estimated that between 6 and 15 percent of people who suffer from severe depression commit suicide (Taube-Schiff & Lau, 2008; Stolberg et al., 2002).

Behavioral Symptoms Depressed people are usually less active and less productive.They spend more time alone and may stay in bed for long periods. One man recalls, "I'd awaken early, but I'd just lie there—what was the use of getting up to a miserable day?" (Kraines & Thetford, 1972, p. 21). Depressed people may also move and even speak more slowly ( Joiner, 2002).

COgnitiVe Symptoms Depressed people hold extremely negative views of themselves.They consider themselves inadequate, undesirable, inferior, per- haps evil.They also blame themselves for nearly every unfortunate event, even things that have nothing to do with them, and they rarely credit themselves for positive achievements.

he Color of Depression

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LOW SELF-ESTEEM

Mood Disorders :11 195

had forgotten it a week after it appeared. But ten years later, Derek was still ruminating over that one editorial. . . .

(Lithe) , & Gordon, 1991, pp. 183-185)

MP.

(Williams, 2008, p. xxiv)

196 :id/CHAPTER 7

51 'Riess at he Happiest of Times omen usually expect the birth of a

child to be a happy experience. But

for 10 to 30 percent of new mothers, the

weeks and months after childbirth bring

clinical depression (Rubertsson et al.,

2005; O'Hara, 2003). Postpartum depres-

sion typically begins within four weeks

after the birth of a child (APA, 2000), and

it is far more severe than simple "baby

blues." It is also different from other post-

partum syndromes such as postpartum psychosis, a problem that will be examined in Chapter 12.

The "baby blues" are so common—as

many as 80 percent of women experience

them—that most researchers consider them

normal. As new mothers try to cope with the

wakeful- nights, rattled emotions, and other

stresses that accompany the arrival of a new

baby, they may experience crying spells, fa-

tigue, anxiety, insomnia, and sadness. These

symptoms usually disappear within days

or weeks (Horowitz et al., 2005, 1995;

Najman et al., 2000).

In postpartum depression, however, de-

pressive symptoms continue and may last

up to a year. The symptoms include extreme

sadness, despair, tearfulness, insomnia,

anxiety, intrusive thoughts, compulsions,

panic attacks, feelings of inability to cope,

and suicidal thoughts (Lindcihl et al., 2005).

The mother-infant relationship and the health

of the child may suffer as a result (Buist

et al., 2006; Monti et al., 2004). Women

who experience postpartum depression have

a 25 to 50 percent chance of developing it

again with a subsequent birth (Stevens

et al., 2002).

Many clinicians believe that the hormonal

changes accompanying childbirth trigger

postpartum depression. All women experi-

ence a kind of hormone "withdrawal" after

delivery, as estrogen and progesterone lev-

els, which rise as much as 50 times above

normal during pregnancy, now drop sharply

to levels for below normal (Horowitz et al.,

2005, 1995). Perhaps some women are

particularly influenced by these dramatic

hormone changes. Still other theorists sug-

gest a genetic predisposition to postpartum

depression. (APA, 2000).

At the same time, psychological and so- ciocultural factors may play important roles

in the disorder. The birth of a baby brings

enormous psychological and social change

(Nydegger, 2006; Gjerdingen & Center,

2005). A woman typically faces changes in

her marital relationship, daily routines, and

social roles. Sleep and relaxation are likely

to decrease, and financial pressures may in-

crease. Perhaps she feels the added stress of

giving up a career—or of trying to maintain

one. This pileup of stress may heighten the

risk of depression (Horowitz et al., 2005;

Swendsen & Mazure, 2000).

Fortunately, treatment can make a big

difference for most women with postpartum

depression. Self-help support groups have

proved extremely helpful for many women

with the disorder (O'Hara, 2003; Stevens

et al., 2002). In addition, many respond

well to the same approaches that are ap-

plied to other forms of depression—anti-

depressant medications, cognitive therapy,

interpersonal psychotherapy, or a combina-

tion of these approaches (Kleiman, 2009;

O'Hara, 2003; Stuart et al., 2003).

However, a large number of women who

would benefit from treatment do not seek

help because they feel ashamed about being

sad at a time that is supposed to be joy-

ous and are concerned about being judged

harshly (WooIhouse et al., 2009; APA,

2000). For them, and for their spouses and

family members, a large dose of education

is in order. Even positive events, such as the

birth of a child, can be stressful if they also

bring major change to one's life. Recogniz-

ing and addressing such feelings are in

everyone's best interest.

AP P f

ia t o /A

!C Inc

., C or d

N ot i

so n 196 :id/CHAPTER 7

51 'Riess at he Happiest of Times omen usually expect the birth of a

child to be a happy experience. But

for 10 to 30 percent of new mothers, the

weeks and months after childbirth bring

clinical depression (Rubertsson et al.,

2005; O'Hara, 2003). Postpartum depres-

sion typically begins within four weeks

after the birth of a child (APA, 2000), and

it is far more severe than simple "baby

blues." It is also different from other post-

partum syndromes such as postpartum psychosis, a problem that will be examined in Chapter 12.

The "baby blues" are so common—as

many as 80 percent of women experience

them—that most researchers consider them

normal. As new mothers try to cope with the

wakeful- nights, rattled emotions, and other

stresses that accompany the arrival of a new

baby, they may experience crying spells, fa-

tigue, anxiety, insomnia, and sadness. These

symptoms usually disappear within days

or weeks (Horowitz et al., 2005, 1995;

Najman et al., 2000).

In postpartum depression, however, de-

pressive symptoms continue and may last

up to a year. The symptoms include extreme

sadness, despair, tearfulness, insomnia,

anxiety, intrusive thoughts, compulsions,

panic attacks, feelings of inability to cope,

and suicidal thoughts (Lindcihl et al., 2005).

The mother-infant relationship and the health

of the child may suffer as a result (Buist

et al., 2006; Monti et al., 2004). Women

who experience postpartum depression have

a 25 to 50 percent chance of developing it

again with a subsequent birth (Stevens

et al., 2002).

Many clinicians believe that the hormonal

changes accompanying childbirth trigger

postpartum depression. All women experi-

ence a kind of hormone "withdrawal" after

delivery, as estrogen and progesterone lev-

els, which rise as much as 50 times above

normal during pregnancy, now drop sharply

to levels for below normal (Horowitz et al.,

2005, 1995). Perhaps some women are

particularly influenced by these dramatic

hormone changes. Still other theorists sug-

gest a genetic predisposition to postpartum

depression. (APA, 2000).

At the same time, psychological and so- ciocultural factors may play important roles

in the disorder. The birth of a baby brings

enormous psychological and social change

(Nydegger, 2006; Gjerdingen & Center,

2005). A woman typically faces changes in

her marital relationship, daily routines, and

social roles. Sleep and relaxation are likely

to decrease, and financial pressures may in-

crease. Perhaps she feels the added stress of

giving up a career—or of trying to maintain

one. This pileup of stress may heighten the

risk of depression (Horowitz et al., 2005;

Swendsen & Mazure, 2000).

Fortunately, treatment can make a big

difference for most women with postpartum

depression. Self-help support groups have

proved extremely helpful for many women

with the disorder (O'Hara, 2003; Stevens

et al., 2002). In addition, many respond

well to the same approaches that are ap-

plied to other forms of depression—anti-

depressant medications, cognitive therapy,

interpersonal psychotherapy, or a combina-

tion of these approaches (Kleiman, 2009;

O'Hara, 2003; Stuart et al., 2003).

However, a large number of women who

would benefit from treatment do not seek

help because they feel ashamed about being

sad at a time that is supposed to be joy-

ous and are concerned about being judged

harshly (WooIhouse et al., 2009; APA,

2000). For them, and for their spouses and

family members, a large dose of education

is in order. Even positive events, such as the

birth of a child, can be stressful if they also

bring major change to one's life. Recogniz-

ing and addressing such feelings are in

everyone's best interest.

AP P f

ia t o /A

!C Inc

., C or d

N ot i

so n

DSM Checklist

API` %Oar)

Mood Disorders :// 1 97

Another cognitive symptom. of depression is pessimism. Sufferers are usually con- vinced that nothing will ever improve, and they feel helpless to change any aspect of their lives. Because they expect the worst, they are likely to procrastinate. Their sense of hopelessness and helplessness makes them especially vulnerable to suicidal thinking (Taube-Schiff & Lau, 2008).

People with depression frequently complain that their intellectual ability is poor. They feel confused, unable to remember things, easily distracted, and unable to solve even the smallest problems. In laboratory studies, depressed individuals do perform more poorly than nondepressed persons on some tasks of memory, attention, and reasoning (Bremner et al., 2004). It may be, however, that these difficulties sometimes reflect mo- tivational problems rather than cognitive ones.

PhySiCal Symptoms People who are depressed often have such physical ailments as headaches, indigestion, constipation, dizzy spells, and general pain (Fishbain, 2000). In fact, many depressions are misdiagnosed as medical problems at first. Disturbances in appetite and sleep are particularly common (Neckelmann et al., 2007; Genchi et al., 2004). Most depressed people eat less, sleep less, and feel more fatigued than they did prior to the disorder. Some, however, eat and sleep excessively.Terrie Williams describes the changes in the pattern of her sleep:

•

At first I didn't notice the change. Then things got worse. I always hated waking up, but slowly it was turning into something deeper; it was less like I didn't want to wake up, and more like couldn't. l didn't feel tired, but I had no energy. I didn't feel sleepy, but I would have welcomed sleep with open arms. I had the sensation of a huge weight, invisible but gigantic, pressing down on me, almost crushing me into the bed and pinning me there.

(Williams, 2008, p. xxii)

omajor depressive disorder0A severe pattern of depression that is disabling and is not caused by such factors as drugs or a general medical condition.

odysthymic disorderoA mood disorder that is similar to but longer-lasting and less disabling than a major depressive disorder.

Diagnosing Unipolar Depression According to DSM-IV-TR, a major depressive episode is a period marked by at least five symptoms of depression and lasting for two weeks or more (see Table 7-1). In extreme cases, the episode may include psychotic symptoms, ones marked by a loss of contact with reality, such as delusions—bizarre ideas without foundation—or hallucinations—perceptions of things that are not actually present. A depressed man with psychotic symptoms may imagine that he can't eat "because my intestines are deteriorating and will soon stop working," or he may believe that he sees his dead wife.

People who experience a major depressive episode without having any history of mania receive a diagnosis of major depressive disorder. Individuals who display a longer-lasting but less disabling pattern of uni- polar depression may receive a diagnosis of dysthymic disorder. When dysthymic disorder leads to major depressive disorder, the sequence is called double depression (Taube-Schiff & Lau, 2008).

Stress and Unipolar Depression Episodes of unipolar depression often seem to be triggered by stressful events (Hammen et al., 2009; Henn &Vollmayr, 2005; Paykel, 2003). In fact, research- ers have found that depressed people experience a greater number of stress- ful life events during the month just before the onset of their disorder than do other people during the same period of time (Monroe & Hadjiyannakis, 2002). Of course, stressful life events also precede other psychological disor- ders, but depressed people report more such events than anybody else.

DSM Checklist

API` %Oar)

Mood Disorders :// 1 97

•

(Williams, 2008, p. xxii)

omajor depressive disorder0A severe pattern of depression that is disabling and is not caused by such factors as drugs or a general medical condition.

odysthymic disorderoA mood disorder that is similar to but longer-lasting and less disabling than a major depressive disorder.

198 : 1/CHAPTER 7

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Some clinicians consider it important to distinguish a reactive (exo- genous) depression, which follows clear-cut stressful events, from an endo- genous depression, which seems to be a response to internal factors (Kessing, 2004). But can one ever know for certain whether a depression is reactive or not? Even if stressful events occurred before the onset of depression, that depression may not be reactive. The events could actually be a co- incidence. Thus, today's clinicians usually concentrate on recognizing both the situational and the internal aspects of any given case of unipolar depression.

The Biological Model of Unipolar Depression Medical researchers have been aware for years that certain diseases and drugs produce mood changes. Could unipolar depression itself have biological causes? Evidence from genetic, biochemical, and anatomical studies suggests that often it does.

Genetic Factors Three kinds of research—family pedigree, twin, and molecular biology gene studies—suggest that some people inherit a predisposition to unipolar depression. Family pedigree studies select people with unipolar depression, examine their relatives, and see whether depres- sion also afflicts other members of the family. If a predisposition to unipo-

lar depression is inherited, the relatives should have a higher rate of depression than the population at large. Researchers have in fact found that as many as 20 percent of those relatives are depressed (see Table 7-2), compared with fewer than 10 percent of the gen- eral population (Taub e-Schiff & Lau, 2008; B erre ttini, 2006).

If a predisposition to unipolar depression is inherited, you might also expect to find a particularly large number of cases among the closer relatives of depressed persons. Twin studies have supported this expectation (Richard & Lyness, 2006). One study looked at nearly 200 pairs of twins. When an identical twin had unipolar depression, there was a 46 percent chance that the other twin would have the same disorder. In contrast, when a fraternal twin had unipolar depression, the other twin had only a 20 percent chance of developing the disorder (McGuffin et al., 1996).

Finally, today's scientists have at their disposal techniques from the field of molecular biology to help them directly identify genes and determine whether certain gene abnor- malities are related to depression. Using such techniques, researchers have found evidence that unipolar depression may be tied to genes on chromosomes 1, 4, 9, 10, 11, 12, 13, 14, 17, 18, 20, 21, 22, and X (Carlson, 2008). For example, a number of researchers have

Mood Disorders Profile

Prevalence Percentage One-year Prevalence

Female to Male

Typical Age at Onset

among First-Degree

Currently Receiving

(Percent) Ratio (Years) Relatives Treatment Major depressive disorder 7.0% 2:1 24-29 Elevated 32.9%

Dysthymic disorder 1.5-5.0% Between 3:2 and 2:1

10-25 Elevated 36.8%

Bipolar I disorder 1.6% 1:6 15-44 Elevated 33.8%

Bipolar II disorder 1 .0% 1:1 15-44 Elevated 33.8%

Cyclothymic disorder 0.4% 1:1 15-25 Elevated Unknown

Source; Taube-Schiff ar Lau, 2003; Kessler et al., 2005, 1994; APA, 2000, 1994; Regier et al., 1993; Weissman et al., 1991.

198 : 1/CHAPTER 7

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Prevalence Percentage One-year Prevalence

Female to Male

Typical Age at Onset

among First-Degree

Currently Receiving

(Percent) Ratio (Years) Relatives Treatment Major depressive disorder 7.0% 2:1 24-29 Elevated 32.9%

Dysthymic disorder 1.5-5.0% Between 3:2 and 2:1

10-25 Elevated 36.8%

Bipolar I disorder 1.6% 1:6 15-44 Elevated 33.8%

Bipolar II disorder 1 .0% 1:1 15-44 Elevated 33.8%

Cyclothymic disorder 0.4% 1:1 15-25 Elevated Unknown

Source; Taube-Schiff ar Lau, 2003; Kessler et al., 2005, 1994; APA, 2000, 1994; Regier et al., 1993; Weissman et al., 1991.

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Mood Disorders :1/ 1 99

found that individuals who are depressed often have an abnormality of their 5-HTT gene, a gene located on chromosome 17 that is responsible for activity of the neurotransmitter serotonin (Hecimovic & Gilliam, 2006). As you will read in the next section, low activity of serotonin is closely tied to depression.

Biocilemicai Factors Low activity of two neurotransmitter chemicals, norepinephrine and serotonin, has been strongly linked to unipolar depression. In the 1950s, several pieces of evidence began to point to this relationship (Carlson, 2008). First, medical research-. ers discovered that certain medications for high blood pressure often caused depression (Ayd, 1956). As it turned out, some of these medications lowered norepinephrine activity and others lowered serotonin. A second piece of evidence was the discovery of the first truly effective antidepressant drugs. Although these drugs were discovered by accident, researchers soon learned that they relieve depression by increasing either norepinephrine or serotonin activity.

For years it was thought that low activity of either norepinephrine or serotonin was capable of producing depression, but investigators now believe that their relation to depression is more complicated (Carlson, 2008; Drevets & Todd, 2005). Research suggests that interactions between serotonin and norepinephrine activity, or between these neurotransmitters and other kinds of neurotransmitters in the brain, rather than the operation of any one neurotransmitter alone, may account for unipolar depression (Thase et al., 2002).

Biological researchers have also learned that the body's endocrine system may play a role in unipolar depression. As you have seen, endocrine glands throughout the body release hormones, chemicals that in turn spur body organs into action (see Chapter 5). People with unipolar depression have been found to have abnormally high levels of cortisol, one of the hormones released by the adrenal glands during times of stress (Neumeister et al., 2005). This relationship is not all that surprising, given that stress- ful events often seem to trigger depression. Another hormone that has been tied to depression is melatonin, sometimes called the "Dracula hormone" because it is released only in the dark. People who experience a recurrence of depression each winter (a pat- tern called seasonal affective disorder) may secrete more melotonin during the winter's long nights than other individuals do (Kasof, 2009; Neto & Araujo, 2004).

Still other biological researchers are starting to believe that unipolar depres- sion is tied more closely to what happens within neurons than to the chemicals that carry messages from neuron to neuron ( Julien, 2008). They believe that activity by key neurotransmitters or hormones ultimately leads to deficiencies of important proteins and other chemicals within neurons—deficiencies that may impair the health of the neurons and lead, in turn, to depression.

The biochemical explanations of unipolar depression have produced much enthusiasm, but research in this area has certain limitations. Some of it has re- lied on analogue studies, which create depression-like symptoms in laboratory animals. Researchers cannot be certain that these symptoms do in fact reflect the human disorder. Similarly, until recent years, technology was limited, and studies of human depression had to measure brain biochemical activity indi- rectly.As a result, investigators could never be certain of the biochemical events that were occurring in the brain. Current studies using newer technology, such as PET and MRI scans, are helping to eliminate such uncertainties about such brain activity.

Brain Anatomy and Brain Circuits In Chapter ____apter 4, you read that many biological researchers now believe that emotional reactions of various kinds are tied to brain circuits—networks of brain structures that work together, trig- gering each other into action and producing a particular kind of emotional reaction. Although research is far from complete, a brain circuit responsible for unipolar depression has also begun to emerge (Insel, 2007). An array of brain- imaging studies point to several brain areas that are likely members of this circuit,

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200 ://CHAPTER 7

° e I ectr o co nvu Is ive therapy (ECT)°A treatment for depression in which elec- trodes attached to a patient's head send an electrical current through the brain, causing a convulsion.

9MAO inhibitoroAn antidepressant drug that prevents the action of the enzyme monoamine oxidase.

particularly the prefrontal cortex, the hippocampus, the amygdala, and Brod- mann Area 25, an area located just under the brain part called the cingulate cortex (see Figure 7-1).

The prefrontal cortex is located within the frontal cortex of the brain. Several imaging studies have found lower activity and blood flow in the prefrontal cortex of depressed research participants than in the pre- frontal cortex of nondepressed individuals (Lambert & Kinsley, 2005; Rajkowska, 2000). However, other studies, focusing on select areas of the prefrontal cortex, have found increases in activity during depres- sion (Carlson, 2008; Drevets, 2001, 2000). Given these varied findings, researchers currently believe that the prefrontal cortex plays a critical role in depression but that the specific nature of this role has yet to be clarified (Higgins & George, 2007).

The prefrontal cortex has strong neural connections with another part of the depression brain circuit, the hippoccunpus. Indeed, messages are both sent and received between the two brain areas. The hippocarnpus is one of the few brain areas to produce new neurons throughout adult- hood, an activity known as neurogenesis (Carlson, 2008). Several stud- ies indicate that such hippocampal neurogenesis decreases dramatically when individuals become depressed (Airan et al., 2007; Sapolsky, 2004, 2000). Moreover, some imaging studies have detected a reduction in the size of the hippocampus among depressed persons (Campbell et al.,

2004; Frodl et al., 2004). You may also recall from Chapters 5 and 6 that the amygdala is a brain area that

repeatedly seems to be involved in the expression of negative emotions and memories. PET and IMRI scans indicate that activity and blood flow in the amygdala is 50 percent greater among depressed persons than nondepressed persons (Drevets, 2001). In fact, one study suggests that as a patient's depression increases, the activity in his or her amygdala increases proportionately (Abercrombie et al., 1998).

The fourth part of the depression brain circuit, Brodmann Area 25, has received enormous attention in recent years (Lozano et al., 2008; Insel, 2007; Mayberg, 2006, 2003). This area, located just under the brain area called the cingulate cortex, tends to be smaller in depressed people than nondepressed people. Moreover, like the amygdala, it is significantly more active among depressed people than among nondepressed people. In fact, brain scans reveal that when a person's depression subsides, the activity in his or her Area 25 decreases significantly.

What Are the Biological Treatments for Unipolar Depression? Usually biological treatment means antidepressant drugs or popular herbal supplements, but for severely depressed individuals who do not respond to other forms of treatment, it some- times means electroconvulsive therapy or a relatively new group of approaches called brain stimulation.

ELECTROCONVULSIVE THERAPY One of the most controversial forms of treatment for de- pression is electroconvulsive therapy, or ECT. In this procedure, two electrodes are attached to the patient's head, and 65 to 140 volts of electricity are passed through the brain for a half second or less. This results in a brain seizure that lasts from 25 seconds to a few minutes. After 6 to 12 such treatments, spaced over two to four weeks, most patients feel less depressed (Medda et al., 2009; Fink, 2007, 2001).

The discovery that electric shock can be therapeutic was made by accident. In the 1930s, clinical researchers mistakenly came to believe that brain seizures, or the convul- sions (severe body spasms) that accompany them, could cure schizophrenia and other psychotic disorders, and so they searched for ways to induce seizures as a treatment for patients with psychosis. One early technique was to give the patients the drug tnetrazol. Another was to give them large doses of insulin (insulin coma therapy).These procedures produced the desired brain seizures, but each was quite dangerous and sometimes even

200 ://CHAPTER 7

° e I ectr o co nvu Is ive therapy (ECT)°A treatment for depression in which elec- trodes attached to a patient's head send an electrical current through the brain, causing a convulsion.

9MAO inhibitoroAn antidepressant drug that prevents the action of the enzyme monoamine oxidase.

particularly the prefrontal cortex, the hippocampus, the amygdala, and Brod- mann Area 25, an area located just under the brain part called the cingulate cortex (see Figure 7-1).

2004; Frodl et al., 2004). You may also recall from Chapters 5 and 6 that the amygdala is a brain area that

Mood Disorders :11 201

the trectIthe I 14 1 patients-are

, I li ill

-slee MSC r

table:

Drugs That Reduce Unipolar Depression

Class/Generic Name Trade Name

Monoamine oxidase inhibitors

caused death. Finally, an Italian psychiatrist named Ugo Cerletti discovered that he could produce seizures more safely by applying electric currents to pa- tients' heads (Cerletti & Bini, 1938). ECT soon became popular and was tried out on a wide range of psychological problems, as new techniques so often are. Its effectiveness with severe depression in particular became apparent.

In the early years of ECT, broken bones and dislocations of the jaw or shoul- ders sometimes resulted from patients' severe convulsions. Today's practitioners avoid this problem by giving the individuals strong muscle relaxants to minimize convulsions.'They also use anesthetics (barbiturates) to put patients to sleep during the procedure, reducing their terror.

Patients who receive ECT typically have difficulty remembering the events immediately before and after their treatments. In most cases, this memory loss clears up within a few months (Calev et al., 1995,1991; Squire & Slater, 1983). Some patients, however, experience gaps in more distant memory, and this form of amnesia can be permanent (Wang, 2007; Squire, 1977).

ECT is clearly effective in treating unipolar depression, although it has been difficult to determine why it works so well (Garrett, 2008). Studies find that between 60 and 80 percent of ECT patients improve (Richard & Lyness, 2006). The procedure seems to be particularly effective in severe cases of de- pression that include delusions. At least 50,000 patients per year are believed to receive ECT each year (Cauchon, 1999).

ANTIDEPRESSANT DRUGS Two kinds of drugs discovered in the 1950s reduce the symptoms of depression: monoamine oxidase (MAO) inhibitors and tricyclics. These drugs have been joined in recent years by a third group, the so -called second generation antidepressants (see Table 7 -3).

The effectiveness of MAO inhibitors as a treatment for unipolar de- pression was discovered accidentally. Physicians noted that iproniazid, a drug being tested on patients with tuberculosis, had an interesting effect: It seemed to make the patients happier (Sandler, 1990). It was found to have the same effect on depressed patients (Kline, 1958; Loomer, Saunders, & Kline, 1957). What this and several related drugs had in common biochemically was that they slowed the body's production of the enzyme monoamine oxidase (MAO). Thus they were called MAO inhibitors.

Normally; brain supplies of the enzyme MAO break down, or degrade, the neurotransmitter norepinephrine. MAO inhibitors block MAO from carry- ing out this activity and thereby stop the destruction of norepinephrine. The result is a rise in norepinephrine activity and, in turn, a reduction of depressive

Isocarboxazid Phenelzine

Tranylcypromine

Selegiline

Tricyclics

Imipramine

Amitriptyline

Doxepin

Trim ipramine

Desipramine

Nortripiyline

Protriptyline

Second-generation

Maprotiline

Amoxopine

Trozodone

Clomipramine

Fluoxetine

Sertraline

Paroxetine

Venlafaxine

Fluvoxamine

Nefazodone

Bupropion

Mirtazapine

Citalopram

Escitaropram

Duloxetine

Reboxetine

Atomoxetine

antidepressants

Ludiomil

Asendin

Desyrel

Anafranil

Prozac

Zoloft

Paxil

Effexor

Generic only

Wellbutrin

Remeron

Celexo

Lexapro

Cymbalta

Edronax

Strattera

Tofranil

Elavil

Adapin; Sinequan Surmontil

Norpramin; Pertofrane

Aventil; Pamelor

Vivactil

Marplan

Nardil

Parnate

Eldepril

( Julien, 2008)

Mood Disorders :11 201

the trectIthe I 14 1 patients-are

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-slee MSC r

table:

Drugs That Reduce Unipolar Depression

Class/Generic Name Trade Name

Monoamine oxidase inhibitors

Isocarboxazid Phenelzine

Tranylcypromine

Selegiline

Tricyclics

Imipramine

Amitriptyline

Doxepin

Trim ipramine

Desipramine

Nortripiyline

Protriptyline

Second-generation

Maprotiline

Amoxopine

Trozodone

Clomipramine

Fluoxetine

Sertraline

Paroxetine

Venlafaxine

Fluvoxamine

Nefazodone

Bupropion

Mirtazapine

Citalopram

Escitaropram

Duloxetine

Reboxetine

Atomoxetine

antidepressants

Ludiomil

Asendin

Desyrel

Anafranil

Prozac

Zoloft

Paxil

Effexor

Generic only

Wellbutrin

Remeron

Celexo

Lexapro

Cymbalta

Edronax

Strattera

Tofranil

Elavil

Adapin; Sinequan Surmontil

Norpramin; Pertofrane

Aventil; Pamelor

Vivactil

Marplan

Nardil

Parnate

Eldepril

( Julien, 2008)

202 .//CHAPTER 7

etricyclicoAn antidepressant drug such as imiprarnine that has three rings in its molecular structure.

°selective serotonin reuptake inhibitors (SSRIs)oA group of second- generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters.

symptoms. Approximately half of depressed patients who take MAO inhibitors are helped by them (Thase et al., 1995).There is, however, a potential danger with regard to these drugs. People who take them experience a dangerous rise in blood pressure if they eat foods containing the chemical tyramine, including such common foods as cheeses, bananas, and certain wines. Thus people on MAO inhibitors must stick to a rigid diet.

The discovery of tricyclics in the 1950s was also accidental. Researchers who were looking for a new drug to combat schizophrenia ran some tests on a drug called imipramine (Kuhn, 1958). They discovered that imipramine was of no help in cases of schizophrenia, but it did relieve unipolar depression in many people.The new drug and related ones became known as tricyclic antidepressants because they all share a three- ring molecular structure.

In hundreds of studies, depressed patients taking tricyclics have improved much more than similar patients taking placebos, although the drugs must be taken for at least 10 days before such improvements take hold ( Julien, 2008; APA, 1993). About 60 to 65 percent of patients who take tricyclics are helped by them (Gitlin, 2002; Hirschfeld, 1999). If the patients stop taking these drugs immediately after obtaining relief, they run a high risk of relapsing within a year. Thus, clinicians typically keep patients on these drugs for five months or more after being free of depressive symptoms—a practice called maintenance therapy (Williams et al., 2009; Mauri et al., 2005).

Most researchers have concluded that tricyclics reduce depression by acting on neu- rotransmitter "reuptake" mechanisms ( Julien, 2008). Remember from Chapter 2 that messages are carried from the "sending" neuron across the synaptic space to a receiv- ing neuron by a neurotransmitter, a chemical released from the ending of the sending neuron. However, there is a complication in this process. While the sending neuron

First Dibs on Antidepressant Drugs?

n our society, the likelihood of being

treated for depression and the types

of treatment received by clients often differ

greatly from ethnic group to ethnic group.

In revealing studies, researchers have

examined the antidepressant prescriptions

written for depressed individuals, particu-

larly Medicaid recipients with depres-

sion (Melfi et al., 2000; Stagnitti, 2005;

Strothers et al., 20051. The following pat-

terns have emerged:

Almost 40 percent of depressed Med- icaid recipients are seen by a mental health provider, irrespective of gender,

race, or ethnic group.

African Americans, Hispanic Ameri- cans, and Native Americans are half as likely as white Americans to be prescribed antidepressant medications on their initial therapy visits.

Although African Americans are less likely to receive antidepressant drugs, some (but not all) clinical trials

suggest that they may be more likely than white Americans to respond to

proper antidepressant medications (Lesser et al., 2007; Lawson, 1996,

1986).

African Americans also receive fewer prescriptions than white Americans for most nonpsychiatric disorders (HiK, 2008; Khandker & Simoni-Wastila,

1998).

Among those individuals prescribed antidepressant drugs, African Ameri- cans are significantly more likely than white Americans to receive tricyclic and older second-generation antide-

pressant drugs, while white Americans are more likely than African Americans to receive newer second-generation antidepressant drugs. The older drugs tend to be less expensive for insurance

providers.

5 Although African Americans are more likely to be prescribed tricyclic anti- depressants, clinical trials suggest that they may be more susceptible than white Americans to the undesired ef- fects of those kinds of drugs (Sramek & Pi, 1996; Strickland et al., 1991).

202 .//CHAPTER 7

etricyclicoAn antidepressant drug such as imiprarnine that has three rings in its molecular structure.

°selective serotonin reuptake inhibitors (SSRIs)oA group of second- generation antidepressant drugs that increase serotonin activity specifically, without affecting other neurotransmitters.

First Dibs on Antidepressant Drugs?

n our society, the likelihood of being

treated for depression and the types

of treatment received by clients often differ

greatly from ethnic group to ethnic group.

In revealing studies, researchers have

examined the antidepressant prescriptions

written for depressed individuals, particu-

larly Medicaid recipients with depres-

sion (Melfi et al., 2000; Stagnitti, 2005;

Strothers et al., 20051. The following pat-

terns have emerged:

Almost 40 percent of depressed Med- icaid recipients are seen by a mental health provider, irrespective of gender,

race, or ethnic group.

African Americans, Hispanic Ameri- cans, and Native Americans are half as likely as white Americans to be prescribed antidepressant medications on their initial therapy visits.

Although African Americans are less likely to receive antidepressant drugs, some (but not all) clinical trials

suggest that they may be more likely than white Americans to respond to

proper antidepressant medications (Lesser et al., 2007; Lawson, 1996,

1986).

African Americans also receive fewer prescriptions than white Americans for most nonpsychiatric disorders (HiK, 2008; Khandker & Simoni-Wastila,

1998).

Among those individuals prescribed antidepressant drugs, African Ameri- cans are significantly more likely than white Americans to receive tricyclic and older second-generation antide-

pressant drugs, while white Americans are more likely than African Americans to receive newer second-generation antidepressant drugs. The older drugs tend to be less expensive for insurance

providers.

Serotonin or --inorepinephrine

Serotonin or norepinephrine reuptake

Serotonin or norepinephrine release

Tricyclic or second- generation

1--

antidepressants block reuptake

Mood Disorders :1/ 203

releases the neurotransmitter, a pumplike mechanism in the neuron's ending immediately starts to reabsorb it in a process called reuptake. The purpose of this reuptake process is to control how long the neurotransmitter remains in the synaptic space and to prevent it from overstimulating the receiving neuron. It may be that the reuptake mechanism is too successful in some people— reducing norepinephrine or serotonin activity too soon, preventing messages from reaching the receiving neu- rons, and producing clinical depression. Tricyclics block this reuptake process, thus increasing neurotransmitter activity (see Figure 7-2).

A third group of effective antidepressant drugs, struc- turally different from the MAO inhibitors and tricyclics, has been developed during the past few decades. Most of these second-generation antidepressants are labeled selective serotonin reuptake inhibitors (SSR1s) be- cause they increase serotonin activity specifically, without affecting norepinephrine or other neurotransmitters.The SSRIs include fluoxetine (trade name Prozac), sertraline (Zoloft), and esdtaloprarn (Lexapro). Newly developed selective norepinephrine reuptake inhibitors, such as atomoxetine (Strattera), which increase norepinephrine activity only, and serotonin-norepinephrine reuptake inhibitors, such as venla-

faxine (Effexor), which increase both serotonin and norepinephrine activity, are also now available.

In effectiveness and speed of action the second-generation antidepressant drugs are about on par with the tricyclics ( Julien, 2008), yet their sales have skyrocketed. Clini- cians often prefer the new antidepressants because it is harder to overdose on them than on the other kinds of antidepressants. In addition, they do not pose the dietary problems of the MAO inhibitors or produce some of the unpleasant side effects of the tricyclics, such as dry mouth and constipation. At the same time, the new antidepressants can produce undesirable side effects of their own. Some people experience a reduction in their sex drive, for example ( Julien, 2008).

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Mood Disorders :1/ 203

faxine (Effexor), which increase both serotonin and norepinephrine activity, are also now available.

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204 ://CHAPTER 7

BRAIN STIMULATION A careful look at treatment studies reveals that one-third of people with unipolar depression are not helped by interventions of any kind. Thus, in recent years, three more promising biological approaches have been developed—vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation.

We each have two vagus nerves, one on each side of our body. The vagus nerve, the longest nerve in the human body, runs from the brain stem through the neck down the chest and on to the abdomen. A number of years ago, a group of depression research- ers surmised that they might be able to stimulate the brain by electrically stimulating the vagus nerve.Their efforts gave birth to a new treatment for depression—vagus nerve stimulation.

In this procedure, a surgeon implants a small device called a pulse generator under the skin of the chest. The surgeon then guides a wire, which extends from the pulse gen- erator, up to the neck and attaches it to the left vagus nerve (see Figure 7-3). Electrical signals periodically travel from the pulse generator through the wire to the vagus nerve. In turn, the stimulated vagus nerve delivers electrical signals to the brain. In studies of severely depressed people who have not responded to any other form of treatment, as many as 40 percent improve significantly when treated with vagus nerve stimulation (Graham, 2007; Nahas et al., 2005).

Transcranial magnetic stimulation (TMS) is another technique that seeks to stimulate the brain without subjecting depressed individuals to the undesired effects or trauma of electroconvulsive therapy. In this procedure, first developed in 1985, the clinician places an electromagnetic coil on or above the patient's head.The coil sends a current into the prefrontal cortex. As you'll remember, at least some parts of the prefrontal cortex of de- pressed people are underactive;TMS appears to increase neuron activity in those areas.A number of studies have found that TMS reduces depression when it is administered daily for two to four weeks (Garrett, 2008; Triggs et al., 1999). The procedure has, however, not yet been approved by the FDA, partly because it can cause significant discomfort to the patient's scalp and can, in some cases, produce seizures (Carlson, 2008).

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204 ://CHAPTER 7

Mood Disorders :lir 205

As you read earlier, researchers have recently linked depression to high activity in. Brodmann Area 25. This finding led neurologist Helen Mayberg and her colleagues (2005) to administer an experimental treatment called deep brain stimulation (DBS) to six severely depressed patients who had previously been unresponsive to all other forms of treatment, including electroconvulsive therapy. The Mayberg team drilled two tiny holes into the patient's skull and implanted electrodes in Area 25. The electrodes were connected to a battery, or "pacemaker," that was implanted in the patient's chest (for men) or stomach (for women). The pacemaker powered the electrodes, sending a steady stream of low-voltage electricity to Area 25. Mayberg's expectation was that this repeated stimulation would reduce Area 25 activity to a normal level and "recalibrate" the entire depression brain circuit.

In the initial study of DBS, four of the six severely depressed patients became al- most depression-free within a matter of months (Mayberg et al., 2005). Subsequent research with other severely depressed individuals has also yielded promising findings (Burkholder, 2008). Understandably, this has produced considerable enthusiasm in the clinical field (Dobbs, 2006), but it is important to recognize that research on DBS is in its earliest stages.

Psychological Models of Unipolar Depression The psychological models that have been most widely applied to unipolar depression are the psychodynamic, behavioral, and cognitive models.The psychodynamic explana- tion has not been strongly supported by research, and the behavioral view has received modest support. In contrast, cognitive explanations have received considerable research support and have gained a large following.

The Psychodynarnic Model Sigmund Freud (1917) and his student Karl Abraham (1916, 1911) developed the first psychodynamic explanation and treatment for depres- sion. Their emphasis on dependence and loss continues to influence today's psychody- namic clinicians.

PSYCHODYNAMIC EXPLANATIONS Freud and Abraham began by noting the similarity be- tween clinical depression and grief in people who lose loved ones: constant weeping, loss of appetite, difficulty sleeping, loss of pleasure in life, and general withdrawal. Ac- cording to the two theorists, a series of unconscious processes is set in motion when a loved one dies. Unable to accept the loss, mourners at first regress to the oral stage of development, the period of total dependency when infants cannot distinguish themselves from their parents. By regressing to this stage, the mourners merge their own identity with that of the person they have lost, and so symbolically regain the lost person. They direct all their feelings for the loved one, including sadness and anger, toward themselves. For most mourners, this reaction is temporary. For some, however, grief worsens over time and they, in fact, become depressed.

Of course, many people become depressed without losing a loved one. To explain why, Freud proposed the concept of symbolic, or imagined, loss, in which persons equate other kinds of events with loss of a loved one. A college student may, for example, experience failure in a calculus course as the loss of her parents, believing that they love her only when she excels academically.

Although many psychodynamic theorists have parted company with Freud and Abraham's theory of depression, it continues to influence current psychodynamic thinking (Busch et al., 2004). For example, object relations theorists, the psychodynamic theorists who emphasize relationships, propose that depression results when people's relationships leave them feeling unsafe and insecure (Allen et al., 2004; Blatt, 2004). People whose parents pushed them toward either excessive dependence or excessive self-reliance are more likely to become depressed when they later lose important relationships.

°symbolic loss0According to Freudian theory, the loss of a valued object (for example, a loss of employment) that is unconsciously interpreted as the loss of a loved one. Also called imagined loss.

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Mood Disorders :lir 205

°symbolic loss0According to Freudian theory, the loss of a valued object (for example, a loss of employment) that is unconsciously interpreted as the loss of a loved one. Also called imagined loss.

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206 ://CHAPTER 7

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The following therapist description of a depressed middle-aged woman illustrates the psychodynamic concepts of dependence, loss of a loved one, and symbolic loss:

Marie Carls . had always felt very attached to her mother. As a matter of fact, they used to call her "Stamp" because she stuck to her mother as a stamp to a letter. She always tried to placate her volcanic mother, to please her in every possible way . . .

After marriage [to Julius], she continued her pattern of submission and compliance. Before her marriage she had difficulty in complying with a volcanic mother, and after her marriage she almost automatically assumed a submissive role. . . .

[W]hen she was thirty years old ... [Marie] and her husband invited Ignatius, who was single, to come and live with them. Ignatius and the patient soon discovered that they had an attraction for each other. They both tried to fight that feeling; but when Julius had to go

to another city for a few days, the so-called infatuation became much more than that. There were a few physical contacts. . . . There was an intense spiritual affinity. . . . A

few months later everybody had to leave the city . . . Nothing was done to maintain contact. Two years later . . . Marie heard that Ignatius had married. She felt ter- ribly alone and despondent...

Her suffering had become more acute as she realized that old age was ap- proaching and she had lost all her chances. Ignatius remained as the memory of lost opportunities. . Her life of compliance and obedience had not permitted her to reach her goal. . . When she became aware of these ideas, she felt even more depressed. . . . She felt that everything she had built in her fife was false or based on a false premise.

(Arieti & Bemporad, 1978, pp. 275-284)

Studies have offered general support for the psychodynamic idea that depression may be triggered by a major loss.When, for example, a depression scale was administered to 1,250 medical patients during visits to their family physicians, the patients whose fathers had died during their childhood scored higher on depression (Barnes & Prosen, 1985). At the same time, research does not indicate that loss always is at the core of depression. In fact, it is estimated that less than 10 percent of all people who experi- ence major losses in life actually become depressed (Bonanno, 2004; Paykel & Cooper, 1992). Moreover, research into the loss-depression link has provided inconsistent find- ings. Though some studies find evidence of a relationship between childhood loss and later depression, others do not (Parker, 1992).

WHAT ARE THE PSYCHODYNAMIC TREATMENTS FOR UNIPOLAR DEPRESSION? Psychodynamic therapists use the same basic procedures with depressed clients as they use with others: They encourage the client to associate freely during therapy; suggest interpretations of the client's associations, dreams, and displays of resistance and transference; and help the person review past events and feelings (Busch et al., 2004). Free association, for example, helped one man recall the early experiences of loss that, according to his therapist, had set the stage for his depression:

Among his earliest memories, possibly the earliest of all, was the recollection of being wheeled in his baby cart under the elevated train structure and left there alone. Another memory that recurred vividly during the analysis was of an operation around the age of five. He was anesthetized and his mother left him with the doctor. He recalled how he had kicked and screamed, raging at her for leaving him.

(Lorand, 1968, pp. 325-326)

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The following therapist description of a depressed middle-aged woman illustrates the psychodynamic concepts of dependence, loss of a loved one, and symbolic loss:

to another city for a few days, the so-called infatuation became much more than that. There were a few physical contacts. . . . There was an intense spiritual affinity. . . . A

few months later everybody had to leave the city . . . Nothing was done to maintain contact. Two years later . . . Marie heard that Ignatius had married. She felt ter- ribly alone and despondent...

(Arieti & Bemporad, 1978, pp. 275-284)

(Lorand, 1968, pp. 325-326)

Mood Disorders :1/ 207

• MT4iiia6:2 - • - HOME • SEND EXPLORE -------- • ' ° " " - "

How Well Do Colleges Treat Depression?

BY DANIEL MCGINN AND RON DEPASQUALE, NEWSWEEK, AUGUST 23, 2004

n the long list of worries that Mom and Dad have when a child goes to college—grades, homesickness, partying—

there's a new issue gaining prominence: the apparent rise in mental illness on campus. More than 1,100 college students com- mit suicide each year, according to estimates by mental-health groups. And even when students aren't in acute distress, they're suffering in surprisingly large numbers. In a 2003 survey by the American College Health Association, more than 40 percent of students reported feeling "so depressed it was difficult to func- tion" at least once during the year. Thirty percent identified them- selves as suffering from an anxiety disorder or depression. . . .

Given that kind of assessment, it's inevitable that mental-health issues are starting to filter into admissions conversations. One counselor at an East Coast private high school says that dur- ing the 2003-04 admissions cycle, officials from two colleges confided they were particularly focused on admitting a class that was "rock solid" emotionally, both to help prevent suicides and to reduce the toll on overbooked school therapists. . .

Since the admissions process requires students to appear flawless, many families avoid disclosing a child's history of emotional problems, especially before they get an acceptance letter. However, parents are starting to ask tough questions about just which kind of mental-health services they can expect from schools

. . . While nearly every school has a counseling office, almost half lack a full-fledged staff psychiatrist, according to Robert Gallagher, a University of Pittsburgh professor who con- ducts an annual survey of college counseling offices. That means it may be difficult for a student to receive prescription drugs to treat depression or anxiety, and that students with serious problems may be referred off campus for treatment. "Not only are the [on-campus] services more accessible, but the people providing the services are more familiar with college pressures," says Gallagher. And while some schools offer unlimited therapy for students, others restrict them to eight or 10 appointments a year. That may be fine for the average student, who often sees a counselor just once or twice to discuss homesickness, a bad grade or a relationship breakup. For those with more serious problems, such limits may mean rushed care.

Experts cite a mix of reasons that campus therapists' offices are so crowded. . . . [According to one explanation,] the quest

to get into a top college has grown so cutthroat for many that more students are emerging from it emotionally damaged. "Kids are burning out sooner and sooner," says Leigh Martin Lowe, director of college counseling at Roland Park Country School in Baltimore. "They're not being allowed to enjoy their teenage years, and many of them end up in college and they don't have the energy or stamina to really turn it on." .. .

For students with [emotional problems], college counselors and therapists say that fact should play some role in their col- lege search. . . . There may also be benefits in choosing smaller schools. . . . According to the University of Pittsburgh study, at colleges with 2,500 or fewer students, health centers had one counselor for every 818 students. At colleges with more than 15,000 students, the counselor-to-student ratio jumped to 1 to 2,426.

The trickiest task faces parents whose children seem 100 per- cent healthy when they leave for college. Donna Satow . and her husband run the Jed Foundation, which helps colleges de- velop strategies for dealing with student depression. . . . Satow advises parents of every student to become informed about mental-health services at their child's school. . [I]n a world where families agonize over finding the cushiest dorm room and the perfect meal plan, it's a question that deserves to be asked.

• • • • • T • .

Despite successful case reports such as this, researchers have found that long-term psychodynainic therapy is only occasionally helpful in cases of unipolar depression (Prochaska & Norcross, 2007). Two features of the approach may help limit its ef- fectiveness. First, depressed clients may be too passive and feel too weary to join fully

Mood Disorders :1/ 207

• MT4iiia6:2 - • - HOME • SEND EXPLORE -------- • ' ° " " - "

How Well Do Colleges Treat Depression?

BY DANIEL MCGINN AND RON DEPASQUALE, NEWSWEEK, AUGUST 23, 2004

n the long list of worries that Mom and Dad have when a child goes to college—grades, homesickness, partying—

Experts cite a mix of reasons that campus therapists' offices are so crowded. . . . [According to one explanation,] the quest

• • • • • T • .

208 //CHAPTER 7

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into the subtle therapy discussions (Widloecher, 2001). And second, they may become discouraged and end treatment too early when this long-term approach is unable to provide the quick relief that they desperately seek. Short-term psychodynamic therapies have performed better than the traditional approaches (Dreissen et al., 2009; Prochaska & Norcross, 2007; Leichsenring, 2001).

The Behavioral Model Behaviorists believe that unipolar depression results from significant changes in the number of rewards and punishments people receive in their lives, and they treat depressed people by helping them build more favorable patterns of reinforcement (Farmer & Chapman, 2008). Clinical researcher Peter Lewinsohn has developed one of the leading behavioral explanations and treatments (Lewinsohn et al., 1990,1984).

THE BEHAVIORAL EXPLANATION Lewinsohn suggests that the positive rewards in life dwindle for some persons, leading them to perform fewer and fewer constructive behaviors.The rewards of campus life, for example, disappear when a young woman graduates from college and takes a job; similarly, an aging baseball player loses the rewards of high salary and praise when his skills deteriorate. Although many people manage to fill their lives with other forms of gratification, some become particularly disheartened.The positive features of their lives decrease even more, and the decline in rewards leads them to perform still fewer constructive behaviors. In this manner, the individuals spiral toward depression.

In a series of studies, Lewinsohn and his colleagues have found that the number of rewards people receive in life is indeed related to the presence or absence of depression. In some of their early studies, not only did depressed participants report fewer positive rewards than nondepressed participants, but when their rewards began to increase, their mood improved as well (Lewinsohn et al., 1979). Similarly, more recent investigations have found a strong relationship between positive life events and feelings of life satisfac- tion and happiness (Lu, 1999).

Lewinsohn and other behaviorists have further proposed that social rewards are par- ticularly important in the downward spiral of depression (Farmer & Chapman, 2008; Lewinsohn et al., 1984). This claim has been supported by research showing that de- pressed persons experience fewer social rewards than nondepressed persons and that as their mood improves, their social rewards increase. Although depressed people are some- times the victims of social circumstances, it may also be that their dark mood and flat behaviors help produce a decline in social rewards (Joiner, 2002; Coyne, 2001).

WHAT ARE THE BEHAVIORAL TREATMENTS FOR UNIPOLAR DEPRESSION? In Lewinsohn's treatment for unipolar depression, therapists use a variety of strategies to help increase the positive behaviors of their clients (Farmer & Chapman, 2008; Lewinsohn et al., 1990, 1982). First, the therapist selects activities that the client considers pleasurable, such as going shopping or taking photos, and encour- ages the person to set up a weekly schedule for engaging in them. Studies have shown that adding positive activities to a person's life can indeed lead to a better mood (Farmer & Chapman, 2008). Second, while reintroducing pleasurable events into a client's life, the therapist makes sure that the person's various behaviors are rewarded correctly. Behaviorists argue that when people become depressed, their negative behaviors—crying, ruminating, com- plaining, or self-criticism—keep others at a distance, reducing chances for rewarding experiences and interactions. To change this pattern, therapists may try to systematically ignore a client's depressive behaviors while praising or otherwise rewarding con- structive statements and behavior, such as going to work. Finally, behavioral therapists may train clients in effective social skills (Segrin, 2000; Hersen et al., 1984). In group therapy programs,

208 //CHAPTER 7

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Mood Disorders 209

for example, members may work together to improve eye contact, facial expression, posture, and other behaviors that send social messages.

These behavioral techniques seem to be of only limited help when just one of them is applied. However, when two or more behavioral techniques are combined, behavioral treatment does appear to reduce depressive symptoms, particularly if the depression is mild (Farmer & Chapman, 2008; Teri & Lewinsohn, 1986). It is worth noting that Lewinsohn himself has combined behavioral techniques with cognitive strategies in recent years, in an approach similar to the cognitive-behavioral treatments discussed in the next section.

The Cognitive Model Cognitive theorists believe that people with unipolar depres- sion persistently view events in negative ways and that such perceptions lead to their dis- order.The two most influential cognitive explanations are the theory of learned helplessness and the theory of negative thinking.

LEARNED HELPLESSNESS Feelings of helplessness fill this account of a young woman's depression:

Mary was 25 years old and had just begun her senior year in college. . . . Asked to re- count how her life had been going recently, Mary began to weep. Sobbing, she said that for the last year or so she felt she was losing control of her life and that recent stresses (starting school again, friction with her boyfriend) had left her feeling worthless and fright- ened. Because of a gradual deterioration in her vision, she was now forced to wear glasses all day. "The glasses make me look terrible," she said, and "I don't look people in the eye much any more." Also, to her dismay, Mary had gained 20 pounds in the past year. She viewed herself as overweight and unattractive. At times she was convinced that with enough money to buy contact lenses and enough time to exercise she could cast off her depression; at other times she believed nothing would help. . . Mary saw her life deterio- rating in other spheres, as well. She felt overwhelmed by schoolwork and, for the first time in her life, was on academic probation. . In addition to her dissatisfaction with her ap- pearance and her fears about her academic future, Mary complained of a lack of friends. Her social network consisted solely of her boyfriend, with whom she was living. Although there were times she experienced this relationship as almost unbearably frustrating, she felt helpless to change it and was pessimistic about its permanence.

(Spitzer et al., 1983, pp. 122-123)

Mary feels that she is "losing control of her life." According to psychologist Martin Seligman (1975), such feelings of helplessness are at the center of her depression. Since the mid-1960s Seligman has developed the learned helplessness theory of depression. It holds that people become depressed when they think (1) that they no longer have control over the reinforcements (the rewards and punishments) in their lives and (2) that they themselves are responsible for this helpless state.

Seligman's theory first began to take shape when he was working with laboratory dogs. In one procedure, he strapped dogs into an apparatus called a hammock, in which they received shocks periodically no matter what they would do. The next day each dog was placed in a shuttle box, a box divided in half by a barrier over which the animal could jump to reach the other side (see Figure 7-4). Seligman applied shocks to the dogs in the box, expecting that they, like other dogs in this situation, would soon learn to escape by jumping over the barrier. However, most of these dogs failed to learn anything in the shuttle box. After a flurry of activity, they simply "lay down and quietly whined" and accepted the shock.

olearned helplessnessoThe perception, based on past experiences, that one has no control over one's reinforcements.

Mood Disorders 209

for example, members may work together to improve eye contact, facial expression, posture, and other behaviors that send social messages.

LEARNED HELPLESSNESS Feelings of helplessness fill this account of a young woman's depression:

(Spitzer et al., 1983, pp. 122-123)

olearned helplessnessoThe perception, based on past experiences, that one has no control over one's reinforcements.

VV .:: C:.Eirlcls a879 1 : 6

210 ://CHAPTER 7

Seligman decided that while receiving inescapable shocks in the hammock the day before, the dogs had learned that they had no control over unpleasant events (shocks) in their lives. That is, they had learned that they were helpless to do anything to change negative situations. Thus, when later they were placed in a new situation (the shuttle box) where they could in fact control their fate, they continued to believe that they were generally helpless. Seligman noted that the effects of learned helplessness greatly resemble the symptoms of human depression, and he proposed that people in fact become depressed after developing a general belief that they have no control over re- inforcements in their lives.

In numerous human and animal studies, participants who undergo helplessness training have displayed reactions similar to depressive symptoms. When, for example, human participants are exposed to uncontrollable negative events, they later score higher than other individuals on a depressive mood survey (Miller & Seligman, 1975). Similarly, helplessness-trained animal subjects lose interest in sexual and social activities—a com- mon symptom of human depression (Lindner, 1968).

The learned helplessness explanation of depression has been revised somewhat over the past two decades.According to a new version of the theory, the attribution-helplessness theory, when people view events as beyond their control, they ask themselves why this is so (Taube-Schiff & Lau, 2008; Abramson et al., 2002, 1989, 1978). If they attribute their present lack of control to some internal cause that is both global and stable ("I am inadequate at everything and I always will be"), they may well feel helpless to prevent future negative outcomes and may experience depression. If they make other kinds of attributions, this reaction is unlikely.

Consider a college student whose girlfriend breaks up with him. If he attributes this loss of control to an internal cause that is both global and stable—"It's my fault [internal], I ruin everything I touch [global], and I always will [stable]" —he then has reason to expect similar losses of control in the future and may generally experience a sense of helplessness.According to the learned helplessness view, he is a prime candidate for depression. If the student had instead attributed the breakup to causes that were more specific ("The way I've behaved the past couple of weeks blew this relationship"), unstable ("I don't know what got into me—I don't usually act like that"), or external ("She never did know what she wanted"), he might not expect to lose control again and would probably not experience helplessness and depression. Hundreds of studies have supported the relationship between styles of attribution, helplessness, and depres- sion (Taube-Schiff & Lau, 2008;Yu & Seligman, 2002).

Some theorists have refined the helplessness model yet again in recent years. They suggest that attributions are likely to cause depression only when they further produce a sense of hopelessness in an indi- vidual (Abela et al., 2004; Abramson et al., 2002, 1989). By taking this factor into consideration, clinicians are often able to predict depression with still greater precision (Robinson & Alloy, 2003).

Although the learned helplessness theory of unipolar depression has been very influential, it too has imperfec- tions. First, much of the learned helplessness research relies on animal subjects (Henn &Vollmayr, 2005). It is impossible to know whether the animals' symptoms do in fact reflect the clinical depression found in humans. Second, the attri- butional feature of the theory raises difficult questions.What about the dogs and rats who learn helplessness? Can animals make attributions, even implicitly?

NEGATIVE THINKING Like Seligman, Aaron Beck believes that negative thinking lies at the heart of depression (Beck & Weishaar, 2008; Beck, 2002, 1991, 1967).According to Beck, maladaptive attitudes, a cognitive triad, errors in thinking, and au- tomatic thoughts combine to produce the clinical disorder.

VV .:: C:.Eirlcls a879 1 : 6

210 ://CHAPTER 7

Mood Disorders :1/ 211

Beck believes that some people develop maladaptive attitudes as children, such as "My general worth is tied to every task I perform" or "If I fail, others will feel repelled by me." The attitudes result from their early interactions and experiences. Many failures are inevitable in a full, active life, so such attitudes are inaccurate and set the stage for all kinds of negative thoughts and reactions. Beck suggests that later in these people's lives, upsetting situations may trigger an extended round of negative thinking. That thinking typically takes three forms, which he calls the cognitive triad: The individuals repeat- edly interpret (1) their experiences, (2) themselves, and (3) their figures in negative ways that lead them to feel depressed. The cognitive triad is at work in the thinking of this depressed person:

I can't bear it. I can't stand the humiliating fact that I'm the only woman in the world who can't take care of her family, take her place as a real wife and mother, and be respected in her community. When I speak to my young son Billy, I know I can't let him down, but I feel so ill-equipped to take care or him; that's what frightens me. I don't know what to do or where to turn; the whole thing is too overwhelming. . . I must be a laughing stock. It's more than l can do to go out and meet people and have the fact pointed up to me so clearly.

(Fieve, 1975)

According to Beck, depressed people also make errors in their thinking. In one com- mon error of logic, they draw arbitrary bfferences—negative conclusions based on little evidence.A man walking through the park, for example, passes a woman who is looking at nearby flowers and concludes, "She's avoiding looking at me." Similarly, depressed people often minimize the significance of positive experiences or magnify that of nega- tive ones. A college student receives an A on a difficult English exam, for example, but concludes that the grade reflects the professor's generosity rather than her own ability (minimization). Later in the week the same student must miss an English class and is convinced that she will be unable to keep up the rest of the semester (magnification).

Finally, depressed people experience automatic thoughts, a steady train of un- pleasant thoughts that keep suggesting to them that they are inadequate and that their situation is hopeless. Beck labels these thoughts "automatic" because they seem to just happen, as if by reflex. In the course of only a few hours, depressed people may be visited by hundreds of such thoughts: "I'm worthless. . I let everyone down.. .. Everyone hates me. . . My responsibilities are overwhelming.. . . I've failed as a parent. . . I'm stupid. ... Everything is difficult for me. . .Things will never change."

Many studies have produced evidence in support of Beck's explanation. Several of them co nfirm that depressed people hold maladaptive attitudes and that the more of these maladaptive attitudes they hold, the more depressed they tend to be (Evans et al., 2005; Whisman & McGarvey, 1995). Other research has found the cognitive triad at work in depressed people (Ridout et al., 2003). And, still other studies have supported Beck's claims about errors in logic (Cole & Turner, 1993). In one study, for example, female participants—some depressed, some not—were asked to read and interpret paragraphs about women in difficult situations. Depressed participants made more errors in logic (such as arbitrary inference) in their interpretations than nondepressed women did (Hammen & Krantz, 1976).

Finally, research has supported Beck's claim that automatic thoughts are tied to depression. In several studies, nondepressed participants who are tricked into reading negative automatic-thought-like statements about themselves become increasingly depressed (Bates et al., 1999; Strickland et al., 1975). In a related line of research, it has been found that people who generally make ruminative responses during their depressed moods—that is,

°cognitive triad0The three forms of negative thinking that Aaron Beck theo- rizes lead people to feel depressed. The triad consists of a negative view of one's experiences, oneself, and the future.

°automatic thoughtsoNumerous unpleasant thoughts that help to cause or maintain depression, anxiety, or other forms of psychological dysfunction.

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Mood Disorders :1/ 211

(Fieve, 1975)

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21 2 ://CHAPTER 7

COGNITIVE TREATMENT FOR UNIPOLAR DEPRESSION To help clients overcome their negative thinking, Beck has developed a treat- ment approach that he calls cognitive therapy. However, as you will see, the approach also includes a number of behavioral techniques, particularly as therapists try to get clients moving again and encourage them to try out new behaviors. Thus, many theorists consider this approach a cognitive - behavioral therapy rather than the purely cognitive intervention implied by its name (Farmer & Chapman, 2008). The approach follows four phases and usu- ally requires fewer than 20 sessions.

Phase 1: Increasing activities and elevating mood Using behavioral techniques to set the stage for cognitive treatment, therapists

first encourage individuals to become more active and confident. Clients spend time during each session preparing a detailed schedule of hourly activities for the coming week. As they become more active from week to week, their mood is expected to improve.

Phase 2: Challenging automatic thoughts Once people are more active and feeling some emotional relief, cognitive therapists begin to educate them about their negative automatic thoughts.The individuals are instructed to recognize and record automatic thoughts as they occur and to bring their lists to each session. Therapist and client then test the reality behind the thoughts, often concluding that they are groundless.

Phase 3: Identifying negative thinking and biases As people begin to recognize the flaws in their automatic thoughts, cognitive therapists show them how illogical thinking processes are contributing to these thoughts. The therapists also guide clients to recognize that almost all their interpretations of events have a negative bias and to change that style of interpretation.

Phase 4: Changing primary attitudes Therapists help clients change the maladaptive attitudes that set the stage for their depression in the first place. As part of the process, therapists often encourage clients to test their attitudes, as in the following therapy discussion:

repeatedly dwell mentally on their mood without acting to change it—experience dejection longer and are more likely to develop clinical depression later in life than people who avoid such ruminations (Levens et al., 2009; Nolen•Hoeksema, 2002).

Therapist: On what do you base this belief that you can't be happy without a man? Patient 1 wos really depressed for a year and a half when I didn't have a man.

Therapist: Is there another reason why you were depressed? Patient As we discussed, I was looking at everything in a distorted way. But f still don't

know if I could be happy if no one was interested in me. Therapist: I don't know either. Is there a way we could find out?

Patient Well, as an experiment, I could not go out on dates for a while and see how feel.

Therapist: I think that's a good idea. Although it has its flaws, the experimental method is still the best way currently available to discover the facts. You're fortunate in being able to run this type of experiment. Now, for the first time in your adult life you aren't attached to a man. if you find you can be happy without a man, this will greatly strengthen you and also make your future relationships all the better.

(Beck et al., 1979, pp. 253-254)

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Phase 1: Increasing activities and elevating mood Using behavioral techniques to set the stage for cognitive treatment, therapists

Therapist: On what do you base this belief that you can't be happy without a man? Patient 1 wos really depressed for a year and a half when I didn't have a man.

Therapist: Is there another reason why you were depressed? Patient As we discussed, I was looking at everything in a distorted way. But f still don't

know if I could be happy if no one was interested in me. Therapist: I don't know either. Is there a way we could find out?

Patient Well, as an experiment, I could not go out on dates for a while and see how feel.

(Beck et al., 1979, pp. 253-254)

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Over the past several decades, hundreds of studies have shown that Beck's therapy and similar cognitive and cognitive-behavioral approaches help with unipolar depression. Depressed adults who receive these thera- pies improve much more than those who receive placebos or no treat- ment at all (Arnow & Post, 2010; Taube-Schiff & Lau, 2008; DeRubeis et al., 2005). Around 50 to 60 percent show a near-total elimination of their symptoms.

It is worth noting that a growing number of today's cognitive- behavioral therapists do not agree with Beck's proposition that individu- als must fully discard their negative cognitions in order to overcome depression. These therapists, the new wave cognitive-behavioral thera- pists about whom you read in Chapters 2 and 4, including those who practice acceptance and commitment therapy (ACT), guide depressed clients to recognize and accept their negative cognitions simply as streams of thinking that flow through their minds, rather than as valuable guides for behavior and decisions. As clients increasingly accept their negative thoughts for what they are, they can better work around the thoughts as they navigate their way through life (StrosahI & Robinson, 2008; Zettle, 2007; Hayes et al., 2006).

The Sociocultural Model of Unipolar Depression Sociocultural theorists propose that unipolar depression is greatly influenced by the social context that surrounds people (see Figure 7-5). Their belief is supported by the finding, discussed earlier, that this disorder is often triggered by outside stressors. Once again, there are two kinds of sociocultural views—the family -social perspective and the on perspective.

The FomiGy-Social Perspective Earlier you read that some behaviorists believe that a decline in social rewards is particularly important in the development of depres- sion. Although presented as part of their behavioral explanation, this view is consistent with the family-social perspective. Indeed, depression has been tied repeatedly to the

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214 ://CHAPTER 7

*interpersonal psychotherapy (IPT)0 A treatment for unipolar depression that is based on the belief that clarifying and changing one's interpersonal problems will help lead to recovery.

°couple therapyeA therapy format in which the therapist works with Iwo peo- ple who share a long-term relationship.

unavailability of social support (Doss et al., 2008; Kendler et al., 2005). Across the United States, people who are separated or divorced display three times the depression rate of married or widowed persons and double the rate of people who have never been mar- ried (Weissman et al., 1991). In some cases, the spouse's depression may contribute to marital problems, a separation, or divorce, but often the interpersonal conflicts and low social support found in troubled relationships seem to lead to depression (Highet et al., 2005;Whisman, 2001).

People whose lives are isolated and without intimacy seem particularly likely to become depressed at times of stress (Kendler et al., 2005; Nezlek et al., 2000). Some highly publicized studies conducted in England a couple of decades ago showed that women who had three or more young children, lacked a close confidante, and had no outside employment were more likely than other women to become depressed after experiencing stressful events (Brown et al., 1995; Brown & Harris, 1978). Studies have also found that depressed people who lack social support remain depressed longer than those who have a supportive spouse or warm friendships (Moos & Cronkite, 1999).

Family-Social Treatments Therapists who use family and social approaches to treat depression help clients change how they deal with the close relationships in their lives.The most effective family-social approaches are interpersonal psychotherapy and couple therapy.

INTERPERSONAL PSYCHOTHERAPY Developed by clinical researchers Gerald Klerman and Myrna Weissman, interpersonal psychotherapy (IPT) holds that any of four interpersonal problem areas may lead to depression and must be addressed: interpersonal loss, interpersonal role dispute, interpersonal role transition, and interpersonal deficits (Stuart, 2009; [German & Weissman, 1992). Over the course of around 16 sessions, IPT therapists address these areas.

First, depressed persons may, as psychodynamic theorists suggest, be experiencing a grief reaction over an important interpersonal loss, the loss of a loved one. In such cases, IPT therapists encourage clients to explore their relationship with the lost person and express any feelings of anger they may discover. Eventually clients develop new ways of remembering the lost person and also seek new relationships.

Second, depressed people may find themselves in the midst of an interpersonal role dispute. Role disputes occur when two people have different expectations of their rela- tionship and of the role each should play. IPT therapists help clients examine whatever role disputes they may be involved in and then develop ways of resolving them.

Depressed people may also be experiencing an interpersonal role transition, brought about by major life changes such as divorce or the birth of a child. They may feel overwhelmed by the role changes that accompany the life change. In such cases IPT therapists help them develop the social supports and skills the new roles require.

Finally, some depressed people display interpersonal deficits, such as extreme shyness or social awkwardness, that prevent them from having intimate relationships. IPT thera- pists may help such individuals recognize their deficits and teach them social skills and assertiveness in order to improve their social effectiveness. In the following discussion, the therapist encourages a depressed man to recognize the effect his behavior has on others:

Client: (After a long pause with eyes downcast, a sad facial expression, and slumped posture) People always make fun of me. I guess I'm just the type of guy who really was meant to be a loner, damn it. (Deep sigh)

Therapist: Could you do that again for me? Client What?

Therapist: The sigh, only a bit deeper. Client: Why? (Pause) Okay, but 1 don't see what . . . okay. (Client sighs again and

smiles.)

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214 ://CHAPTER 7

*interpersonal psychotherapy (IPT)0 A treatment for unipolar depression that is based on the belief that clarifying and changing one's interpersonal problems will help lead to recovery.

°couple therapyeA therapy format in which the therapist works with Iwo peo- ple who share a long-term relationship.

Therapist: Could you do that again for me? Client What?

Therapist: The sigh, only a bit deeper. Client: Why? (Pause) Okay, but 1 don't see what . . . okay. (Client sighs again and

smiles.)

Mood Disorders 215

Therapist: Weil, that time you smiled, but mostly when you sigh and look so sad I get the feeling that I better leave you alone in your misery, that I should walk on eggshells and not get too chummy or l might hurt you even more.

Client (A bit of anger in his voice) Well, excuse me! 1 was only trying to tell you how I felt.

Therapist: I know you felt miserable, but I also got the message that you wonted to keep me at a distance, that I had no way to reach you.

Client: (Slowly) I feel like a loner, I feel that even you don't care about rne—making fun of me.

Therapist / wonder if other folks need to pass this test, too?

(Beier & Young, 1984, 9. 270)

Studies suggest that IPT and related interpersonal treatments for depression have a success rate similar to that of cognitive and cognitive- behavioral therapies (Markowitz, 2006; Weissman & Markowitz, 2002). That is, symptoms largely disappear in 50 to 60 percent of clients who receive treatment. Not surprisingly, IPT is considered especially useful for depressed people who are struggling with social conflicts or under- going changes in their careers or social roles (Weissman & Markowitz, 2002).

COUPLE THERAPY As you have read, depression can result from marital discord, and recovery from depression is often slower for people who do not receive support from their spouse (Beach et al., 2008). In fact, as many as half of all depressed clients may be in a dysfunctional rela- tionship. Thus many cases of depression have been treated by couple therapy, the approach in which a therapist works with two people who share a long-term relationship.

Therapists who offer behavioral marital therapy help spouses change harmful marital behavior by teaching them specific communication and problem-solving skills (see Chapter 2). When a depressed person's marriage is filled with conflict, this approach and similar couple thera- pies may be as effective as individual cognitive therapy, interpersonal psychotherapy, or drug therapy in helping to reduce depression (Barbato & D'Avanzo, 2008; Snyder & Castellani, 2006).

The Muitlicuitured Perspective Two issues have captured the interest of multi- cultural depression theorists: (1) links between gender and depression and (2) ties between cultural and ethnic background and depression.

GENDER AND DEPRESSION As you have read, a strong link exists between gender and depression. Women in most countries are at least twice as likely as men to receive a diagnosis of unipolar depression (Lara, 2008; Whiffen & Demidenko, 2006). A variety of explanations for this gender difference have been offered (Russo & Tartaro, 2008; Nolen-Hoeksema, 2002, 1995, 1990).

The art fact theory holds that women and men are equally prone to depression but that clinicians often fail to detect depression in men (Brommelhoff et al., 2004). Perhaps depressed women display more emotional symptoms, such as sadness and crying, which are easily diagnosed, while depressed. men mask their depression behind traditionally "masculine'" symptoms such as anger. Although a popular explanation, this view has failed to receive consistent research support (McSweeney, 2004).

The hormone explanation holds that hormone changes trigger depression in many women (Parker & Brotchie, 2004). A woman's biological life from her early teens to middle age is marked by frequent changes in hormone levels. Gender differences in

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Mood Disorders 215

Client (A bit of anger in his voice) Well, excuse me! 1 was only trying to tell you how I felt.

Therapist: I know you felt miserable, but I also got the message that you wonted to keep me at a distance, that I had no way to reach you.

Client: (Slowly) I feel like a loner, I feel that even you don't care about rne—making fun of me.

Therapist / wonder if other folks need to pass this test, too?

(Beier & Young, 1984, 9. 270)

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216 :IICHAPTER 7

rates of depression also span these same years. Research suggests, however, that hormone changes alone are not responsible for the high levels of depression in women (Kessler et al., 2006; Whiffen & Demidenko, 2006). Important social and life events that occur at puberty, pregnancy, and menopause could likewise have an effect.

The life stress theory suggests that women in our society experience more stress than men (Kessler et al., 2006; Keyes & Goodman, 2006). On average they face more poverty, more menial jobs, less adequate housing, and more discrimi- nation than men—all factors that have been linked to depression. And in many homes, women bear a disproportionate share of responsibility for child care and housework.

The body dissatisfaction explanation states that females in Western society are taught, almost from birth, to seek a low body weight and slender body shape— goals that are unreasonable, unhealthy, and often unattainable.As you will observe in Chapter 9, the cultural standard for males is much more lenient. As girls ap- proach adolescence, peer pressure may produce greater and greater dissatisfaction with their weight and body, increasing the likelihood of depression. Consistent with this theory, gender differences in depression do indeed first appear during adolescence (Avenevoli et al., 2008), and persons with eating disorders often experience high levels of depression (Stewart & Williamson, 2008). However, it is not clear that eating and weight concerns actually cause depression; they may instead be the result of depression.

The lack -of-control theory picks up on the learned helplessness research and argues that women may be more prone to depression because they feel less control than men over their lives. It has been found that victimization of any kind, from burglary to rape, often produces a general sense of helplessness and

increases the symptoms of depression. Women in our society are more likely than men to be victims, particularly of sexual assault and child abuse (Whiffen & Demidenko, 2006; Nolen-Hoeksema, 2002).

A final explanation for the gender differences found in depression is the rumination theory. As you read earlier, rumination is the tendency to keep focusing on one's feelings when depressed and to consider repeatedly the causes and consequences of that depres- sion ("Why am I so down? . . . I won't be able to finish my work if I keep going like this. . ."). It turns out that women are more likely than men to ruminate when their moods darken, perhaps making them more vulnerable to the onset of clinical depression (Nolen-Hoeksema & Corte, 2004; Nolen-Hoeksema, 2002, 2000).

Each of these explanations for the gender difference in unipolar depression offers food for thought. Each has gathered just enough supporting evidence to make it inter- esting and just enough evidence to the contrary to raise questions about its usefulness (Russo & Tartaro, 2008). Thus, at present, the gender difference in depression remains one of the most talked about but least understood phenomena in the clinical field.

CULTURAL BACKGROUND AND DEPRESSION Research suggests that depression is a worldwide phenomenon, and certain symptoms of this disorder seem to be constant across all coun- tries.A landmark study of four countries—Canada, Switzerland, Iran, and Japan—found that the great majority of depressed people in those very different countries reported symptoms of sadness, joylessness, anxiety, tension, lack of energy, loss of interest, loss of ability to concentrate, ideas of insufficiency, and thoughts of suicide (Matsumoto & Juang, 2008;WHO, 1983). Beyond these core symptoms, however, the picture of depres- sion varies from country to country (Matsumoto & Juang, 2008; Kleinman, 2004; Tsai & Chentsova-Dutton, 2002). Depressed people in non-Western countries—China and Nigeria, for example—are more likely to be troubled by physical symptoms such as fa- tigue, weakness, sleep disturbances, and weight loss. Depression in those countries is less often marked by cognitive symptoms such as self-blame, low self-esteem, and guilt.

Within the United States, researchers have found few differences in the symptoms of depression among members of different ethnic or racial groups. Nor have they found differences in the overall rates of depression between such minority groups. Investigators

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216 :IICHAPTER 7

increases the symptoms of depression. Women in our society are more likely than men to be victims, particularly of sexual assault and child abuse (Whiffen & Demidenko, 2006; Nolen-Hoeksema, 2002).

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do, however, sometimes find striking differences when they look at specific ethnic popu- lations living under special circumstances (Matsumoto & Juang, 2008; Ayalon &Young, 2003). A study of one Native American conununity in the United States, for example, showed that the lifetime risk of developing depression was 37 percent among women, 19 percent among men, and 28 percent overall, much higher than the risk in the general United States population (Kinzie et al., 1992). High prevalence rates of this kind may be linked to the terrible social and economic pressures faced by the people who live on Native American reservations. Similarly, in a survey of Hispanic and African Americans residing in public housing, almost half of the respondents reported that they were suf- fering from depression (Bazargan et al., 2005). Within these minority populations, the likelihood o f being depressed rose along with the individual's degree of poverty, family size, and number of health problems.

Multicuiturai Treatments In Chapter 2, you read that culture-sensitive therapies seek to address the unique issues faced by members of cultural minority groups (Carten, 2006). Such approaches typically include special cultural training of the therapists; heightened awareness by therapists of their clients' cultural values and the culture-related stressors, prejudices, and stereotypes faced by the clients; and efforts by therapists to help clients recognize the impact of their own culture and the dominant culture on their self- views and behaviors (Prochaska & Norcross, 2007).

In the treatment of unipolar depression, culture-sensitive approaches increasingly are being co mbined with traditional forms of psychotherapy to help improve the likeli- hood of minority clients overcoming their disorders. A number of today's therapists, for example, offer cognitive-behavioral therapy for depressed minority clients while also focusing on the clients' economic pressures, minority identity, and related cultural is- sues (Stacciarini et al., 2007; Satterfield, 2002). A range of studies indicate that Hispanic American, African American, Native American, and Asian American clients are more likely to overcome their depressive disorders when a culture-sensitive focus is added to the form of psychotherapy that they are otherwise receiving (Dwight Johnson& Lagomasino, 2007; Ward, 2007).

Unipolcw Depression

People with unipolar depression, the most common pattern of mood disorder, suf- fer from depression only. The symptoms span five areas of functioning: emotional, motivational, behavioral, cognitive, and physical. Women are at least twice as likely as men to experience severe unipolar depression.

According to the biological view, low activity of two neurotransmitters, norepi- nephrine and serotonin, helps cause depression. Hormonal factors may also be at work. So too may deficiencies of key proteins and other chemicals within certain neurons. Brain-imaging research has also tied depression to abnormalities in a cir- cuit of brain areas, including the prefrontal cortex, hippocampus, amygdala, and Brodmann Area 25. All such biological problems may be linked to genetic factors. Most biological treatments consist of antidepressant drugs, but electroconvulsant therapy is still used to treat some severe cases of depression, and several brain stimulation techniques recently have been developed to treat severely depressed patients who are unresponsive to other forms of treatment.

According to the psychodynamic view, certain people who experience real or imagined losses may regress to an earlier stage of development, fuse with the person they have lost, and eventually become depressed. Psychodynamic therapists try to help persons with unipolar depression recognize and work through their losses and excessive dependence on others.

The behavioral view says that when people experience a large reduction in their positive rewards in life, they are more and more likely to become depressed.

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The behavioral view says that when people experience a large reduction in their positive rewards in life, they are more and more likely to become depressed.

T.1111;,':17

218 ://CHAPTER 7

Paternai Postpartum Depression

Behavioral therapists try to reintroduce clients to activities that they once found plea- surable, reward nondepressive behaviors, and teach effective social skills.

According to Seligman's learned helplessness theory, people become depressed when they believe that they have lost control over the reinforcements in their lives and when they attribute this loss to causes that are internal, global, and stable. According to Beck's theory of negative thinking, maladaptive attitudes, the cogni- tive triad, errors in thinking, and automatic thoughts help produce unipolar depres- sion. Beck's cognitive therapy for depression helps clients increase their activities, challenge their automatic thoughts, identify negative thinking, and change their maladaptive attitudes.

Sociocultural theories propose that unipolar depression is influenced by social and cultural factors. Family-social theorists point out that a low level of social sup- port is often linked to unipolar depression. Correspondingly, interpersonal psycho- therapy and couple therapy are often helpful in cases of depression. Multicultural theories have noted that the character and prevalence of depression often varies by gender and sometimes by culture, an issue that culture-sensitive therapies for depression seek to address.

*Bipolar Disorders People with a bipolar disorder experience both the lows of depression and the highs of mania. Many describe their life as an emotional roller coaster, as they shift back and forth between extreme moods.A number of sufferers eventually become suicidal. Their roller- coaster ride and its impact on relatives and friends are seen in the following case study:

In his early school years he had been a remarkable student and had shown a gift for watercolor and oils. Later he had studied art in Paris and married an English girl he had met there. Eventually they had settled in London.

Ten years later, when he was thirty-four years old, he had persuaded his wife and only son to accompany him to Honolulu, where, he assured them, he would be considered famous. He felt he would be able to sell his paintings at many times the prices he could get in London. According to his wife, he had been in an accelerated state, but at that time the family had left, unsuspecting, believing with the patient in their imminent good fortune. When they arrived they found almost no one in the art world that he was supposed to know. There were no connections for sales and deals in Hawaii that he had anticipated. Settling down, the patient began to behave more peculiarly than ever. After enduring several months of the patient's exhilaration, overactivity, weight loss, constant talking, and unbelievably little sleep, the young wife and child began to fear for his sanity. None of his plans materialized. After five months in the Pacific, with finances growing thin, the patient's overactivity subsided and he fell into a depression.

During that period he refused to move, paint, or leave the house. He lost twenty pounds, became utterly dependent on his wife, and insisted on seeing none of the friends he had accumulated in his manic state. His despondency became so severe that several doctors came to the house and advised psychiatric hospitalization. He quickly agreed and received twelve electroshock treatments, which relieved his depressed state. Soon after- ward he began to paint again and to sell his work modestly. Recognition began to come from galleries and critics in the Far East. Several reviews acclaimed his work as exception- ally brilliant.

This was the beginning of the lifelong career of his moodswing. While still in Honolulu, he once again became severely depressed. . Four years later he returned to London in

T.1111;,':17

218 ://CHAPTER 7

Paternai Postpartum Depression

Behavioral therapists try to reintroduce clients to activities that they once found plea- surable, reward nondepressive behaviors, and teach effective social skills.

This was the beginning of the lifelong career of his moodswing. While still in Honolulu, he once again became severely depressed. . Four years later he returned to London in

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a high. . . When this manic period subsided and he surveyed the wreckage of his life, an eight-month interval of normal mood followed, after which he again switched into a profound depression.

(Fieve, 1975, pp. 64-65)

•

What Are the Symptoms of Mania? Unlike people sunk in the gloom of depression, those in a state of mania typically ex- perience dramatic and inappropriate rises in mood. The symptoms of mania span the same areas of functioning—emotional, motivational, behavioral, cognitive, and physical—as those of depression, but mania affects those areas in an opposite way.

A person in the throes of mania has active, powerful emotions in search of an outlet. The mood of euphoric joy and well-being is out of all proportion to the actual happen- ings in the person's life. Not every person with mania is a picture of happiness, however. Some instead become very irritable and angry, especially when others get in the way of their exaggerated ambitions.

In the motivational realm, people with mania seem to want constant excitement, involvement, and companionship. They enthusiastically seek out new friends and old, new interests and old, and have little awareness that their social style is overwhelming, domineering, and excessive.

The behavior of people with mania is usually very active. They move quickly, as though there were not enough time to do everything they want to do. They may talk rapidly and loudly, their conversations filled with jokes and efforts to be clever or, con- versely, with complaints and verbal outbursts. Flamboyance is not uncommon: dressing in flashy clothes, giving large sums of money to strangers, or even getting involved in dangerous activities.

In the cognitive realm, people with mania usually show poor judgment and plan- ning, as if they feel too good or move too fast to consider possible pitfalls. Filled with optimism, they rarely listen when others try to slow them down.They may also hold an inflated opinion of themselves, and sometimes their self-esteem approaches grandiosity. During severe episodes of mania, some have trouble remaining coherent or in touch with reality.

Finally, in the physical realm, people with mania feel remarkably energetic. They typically get little sleep yet feel and act wide awake. Even if they miss a night or two of sleep, their energy level may remain high.

Diagnosing Bipolar Disorders People are considered to be in a full manic episode when for at least one week they display an abnormally high or irritable mood, along with at least three other symptoms of mania (see Table 7-4 on the next page).The episode may even include psychotic features such as delusions or hallucinations.When the symptoms of mania are less severe (causing little impairment), the person is said to be experiencing a lzypomanic episode (APA, 2000).

DSM-IV-TR distinguishes two kinds of bipolar disorders—bipolar I and bipolar II. People with bipolar I disorder have full manic and major depressive episodes. Most of them experience an alternation of the episodes; for example, weeks of mania followed by a period of wellness, followed, in turn, by an episode of depression. Some people, however, have mixed episodes, in which they swing from manic to depressive symptoms and back again on the same day. In bipolar II disorder, hypomanic—that is, mildly manic—episodes alternate with major depressive episodes over the course of time. Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder ( Julien, 2008). In most cases, the individual's depressive episodes outnumber his or her manic episodes ( Julien, 2008).

Surveys from around the world indicate that between l and 2.6 percent of all adults suffer from a bipolar disorder at any given time (Merikangas et al., 2007; Kessler et al.,

°bipolar I disordereA type of bipolar disorder marked by full manic and major depressive episodes.

°bipolar II disordereA type of bipolar disorder marked by mildly manic (hypo- manic) episodes and major depressive episodes.

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a high. . . When this manic period subsided and he surveyed the wreckage of his life, an eight-month interval of normal mood followed, after which he again switched into a profound depression.

(Fieve, 1975, pp. 64-65)

•

Surveys from around the world indicate that between l and 2.6 percent of all adults suffer from a bipolar disorder at any given time (Merikangas et al., 2007; Kessler et al.,

°bipolar I disordereA type of bipolar disorder marked by full manic and major depressive episodes.

°bipolar II disordereA type of bipolar disorder marked by mildly manic (hypo- manic) episodes and major depressive episodes.

220 .1/CHAPTER 7

table:

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2005).The disorders appear to be equally common in women and men and among all socioeconomic classes and ethnic groups (Shastry, 2005). Onset usually occurs between the ages of 15 and 44 years. In most untreated cases of bipolar disorder, the manic and depressive episodes eventually subside, only to recur at a later time (APA, 2000).

When a person experiences numerous periods of hypomanic symptoms and mild depressive symptoms, DSM-IV-TR assigns a diagnosis of cyclothymic disorder The symp- toms of this milder form of bipolar disorder continue for two or more years, inter- rupted occasionally by normal moods that may last for only days or weeks. At least 0.4 percent of the population develops cyclothymic disorder (APA, 2000). In some cases, the milder symptoms eventually blossom into a bipolar I or II disorder.

What Causes Bipolar Disorders? Throughout the first half of the twentieth century, the search for the cause of bipolar disorders made little progress. More recently, biological research has produced some promising clues. The biological insights have come from research into neurotransmitter activity, ion activity, brain structirre, and genetic factors.

Neurotransmitiers Could overactivity of norepinephrine be related to mania? This was the expectation of clinicians back in the 1960s after investigators first found a relation- ship between low norepinephrine activity and unipolar depression (Schildkraut, 1965). Several studies did indeed find the norepinephrine activity of persons with mania to be higher than that of depressed or control research participants (Post et al., 1980, 1978).

Because serotonin activity often parallels norepinephrine activity in unipolar de- pression, theorists at first expected that mania would also be related to high serotonin activity, but no such relationship has been found. Instead, research suggests that mania, like depression, may be linked to low serotonin activity (Shastry, 2005; Sobczak et al.,

220 .1/CHAPTER 7

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2002). Perhaps low activity of serotonin opens the door to a mood disorder and permits the activity of norepinephrine (or perhaps other neurotransmitters) to define the par- ticular form the disorder will take. That is, low serotonin activity accompanied by low norepinephrine activity may lead to depression; low serotonin activity accompanied by high norepinephrine activity may lead to mania.

on Activity Electrically charged ions help transmit messages down each neuron's axon to its nerve endings. Positively charged sodium ions (Na+) sit on both sides of a neuron's cell membrane. When the neuron is at rest, more sodium ions sit outside the membrane.When the neuron receives an incoming message at its receptor sites, however, pores in the 'cell membrane open, allowing the sodium ions to flow to the inside of the membrane, thus increasing the positive charge inside the neuron. This starts a wave of electrical activity that travels down the length of the neuron and results in its "firing." After the neuron "fires,"potassium ions (K+) flow from the inside of the neuron across the cell membrane to the outside, helping to return the neuron to its original resting state.

If messages are to be relayed effectively down the axon, the ions must be able to travel easily between the outside and the inside of the neural membrane. Sonic theorists believe that irregularities in the transport of these ions may cause neurons to fire too easily (resulting in mania) or to stubbornly resist firing (resulting in depression) (Li & El-Mallakh, 2004; El-Mallakh & Huff, 2001). Not surprisingly, investigators have found membrane defects in the neurons of people suffering from bipolar disorder and have observed abnormal functioning in the proteins that help transport ions across a neuron's membrane (Sassi & Soares, 2002).

Brain Structure Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorders (Lambert & Linsley, 2005; Shastry, 2005). For example, the basal ganglia and cerebellum of these individuals tend to be smaller than those of other people. It is not clear what role these and other structural abnormalities play in bipolar disorders.

Genetic Factors Many theorists believe that people inherit a biological predisposi- tion to develop bipolar disorders. Family pedigree studies support this idea (Maier et al., 2005). Identical twins of persons with a bipolar disorder have a 40 percent likelihood of developing the same disorder, and fraternal twins, siblings, and other close relatives of such persons have a 5 to 10 percent likelihood, compared to the 1 to 2.6 percent preva- lence rate in the general population.

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Mood Disorders :1/ 221

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Researchers have also conducted genetic linkage studies to identify possible patterns in the inheritance of bipolar disorders. They select large families that have had high rates of a disorder over several generations, observe the pattern of distribution of the disorder among family members, and determine whether it closely follows a predict- able pattern of inheritance. Still other researchers have used techniques from molecular biology to examine genetic factors. These various undertakings have linked bipolar disorders to genes on chromosomes 1, 4, 6, 10, 11, 12, 13, 15, 18, 21, and 22 (Schulze & McMahon, 2009; Maier et al., 2005; Baron, 2002). Such wide-ranging findings suggest that a number of genetic abnormalities probably combine to help bring about bipolar disorders.

What Are the Treatments for Bipolar Disorders? Until the latter part of the twentieth century, people with bipolar disorders were des- tined to spend their lives on an emotional roller coaster. Psychotherapists reported almost no success, and antidepressant drugs were of limited help (Prien et al., 1974). In fact, the drugs sometimes triggered a manic episode (Post, 2005; Suppes et al., 2005).

Lithium and Other Mood Stabilizers This gloomy picture changed dramati- cally in 1970 when the FDA approved the use of lithium, a silvery-white element found in various simple mineral salts throughout the natural world, as a treatment for bipolar disorder. Other kinds of mood stabilizing, or antibipolar, drugs have since been developed, and several of them, including the antiseizure drugs carbamazepine (Tegretol) or valproate (Depakote), are now used widely, either because they produce fewer undesired effects than lithium or because they are even more effective than lithium. Some people respond best to a combination of these various mood stabilizers, and still others do well with a combination of mood stabilizers and atypical antipsychotic drugs, medications that you will read about in Chapter 12 (Donner, 2005). Nevertheless, it was lithium that first brought hope to those suffering from bipolar disorder.

All manner of research has attested to the effectiveness of lithium and other mood stabilizers in treating manic episodes (Grof, 2005). More than 60 percent of patients with mania improve on these medications. In addition, most such individuals experience fewer new episodes as long as they continue taking the medications (Carney & Goodwin, 2005). One study found that the risk of relapse is 28 times greater if patients stop taking a mood stabilizer (Suppes et al., 1991). Thus today's clinicians usually continue patients on some level of a mood stabilizing drug even after their manic episodes subside ( Julien, 2008; Swann, 2005).

The mood stabilizers also help those with bipolar disorder overcome their depressive episodes, though to a lesser degree than they help with their manic episodes (El-Mallakh, 2006). Given the drugs' less powerful impact on depressive episodes, many clinicians use

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Mood Disorders :1,1 223

Abnormality and the Arts •

bnorrnality and Creativity: A Delicate Balance

li I -

;mania, anxiety, and even confusion , p to a point, states of depression, mania

can be useful. This may be particularly true in the arts. The ancient Greeks believed that various forms of "divine madness" inspired creative acts, from poetry to performance (Ludwig, 1995). Even today many people expect "creative geniuses" to be psychologically disturbed. A popu- lar image of the artist includes a glass of liquor, a cigarette, and a tormented expres- sion. Classic examples include poet Sylvia Plath, who experienced depression most of her life and eventually committed suicide, and dancer Vaslav Nilinsky, who suffered from schizophrenia and spent many years in institutions. In fact, a number of stud- ies indicate that artists and writers are somewhat more likely than others to suffer from mental disorders, particularly mood disorders (Sample, 2005; lauronen et al., 2004; Jamison, 1995).

Why might creative people be prone to psychological disorders? Some may be predisposed to such disorders long before

they begin their artistic careers; the careers may simply bring attention to their emo- tional struggles (Ludwig, 1995). Indeed, creative people often have a family history of psychological problems. A number also have experienced intense psychological trauma during childhood. English novelist and essayist Virginia Woolf, for example, endured sexual abuse as a child.

Another reason for the creativity link may be that creative endeavors create emo- tional turmoil that is overwhelming. Truman Capote said that writing his famous book In Cold Blood "killed" him psychologically. Before writing this account of the brutal murders of a family, he considered himself "a stable person.... Afterward something happened to me" (Ludwig, 1995).

Yet a third explanation for the link between creativity and psychological disorders is that the creative professions offer a welcome climate for those with psychological disturbances. In the worlds of poetry, painting, and acting, for exam- ple, emotional expression and personal

turmoil are valued as sources of inspira- tion and success (Sample, 2005; Ludwig, 1995).

Much remains to be learned about the relationship between emotional turmoil and creativity, but work in this area has already clarified two important points. First, psychological disturbance is hardly a requirement for creativity. Many "cre- ative geniuses" are, in fact, psychologi- cally stable and happy throughout their entire lives (Schlesinger & Ismail, 2004). Second, mild psychological disturbances relate to creative achievement much more strongly than severe disturbances do. For example, nineteenth-century composer Robert Schumann produced 27 works during one mildly hypomanic year but next to nothing during years when he was severely depressed and suicidal (Jamison, 1995).

Some artists worry that their creativity would disappear if their psychological suffering were to stop. In fact, however, research suggests that successful treat- ment for severe psychological disorders more often than not improves the creative process (Jamison, 1995; Ludwig, 1995). Romantic notions aside, severe mental dys- functioning has little redeeming value, in the arts or anywhere else.

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Mood Disorders :1,1 223

Abnormality and the Arts •

bnorrnality and Creativity: A Delicate Balance

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Why might creative people be prone to psychological disorders? Some may be predisposed to such disorders long before

turmoil are valued as sources of inspira- tion and success (Sample, 2005; Ludwig, 1995).

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a combination of mood stabilizers and antidepressant drugs to treat bipolar depression (Grunze, 2005; Swann, 2005). In addition, continued doses of mood stabilizers (or mood stabilizers combined with antidepressant drugs) apparently reduce the risk of future de- pressive episodes, just as they seem to prevent the return of manic episodes (Carney & Goodwin, 2005).

Researchers do not fully understand how mood stabilizing drugs operate (Lambert Kinsley, 2005).They suspect that the drugs change synaptic activity in neurons, but in

a way different from that of antidepressant drugs.The firing of a neuron actually consists of several phases that ensue at lightning speed. When the neurotransmitter binds to a receptor on the receiving neuron, a series of changes occur within the receiving neuron to set the stage for firing. The substances in the neuron that carry out those changes are often called second messengers because they relay the original message from the receptor site to the firing mechanism of the neuron. (The neurotransmitter itself is considered the first messenger) Whereas antidepressant drugs affect a neuron's initial reception of neurotransmitters, mood stabilizers appear to affect a neuron's second mes- sengers ( Julien, 2008).

It has been found that lithium and other mood stabilizing drugs also increase the production of neuroprotective proteins—key proteins within certain neurons whose job is to prevent cell death. In so doing, the drugs may increase the health and functioning of those cells and, in turn, reduce bipolar symptoms (Gray et al., 2003; Ren et al., 2003).

Adiunctive Psychotherapy Psychotherapy alone is rarely helpful for persons with bipolar disorder. At the same time, clinicians have learned that mood stabilizing drugs alone are not always sufficient either.Thirty percent or more of patients with these dis- orders may not respond to lithium or a related drug, may not receive the proper dose, or may relapse while taking it. In addition, a number of patients stop taking mood stabilizers on their own ( Julien, 2008; Lewis, 2005).

In view of these problems, many clinicians now use individual, group, or family therapy as an adjunct to mood stabilizing drugs (Leahy, 2005;Vieta, 2005). Most often, therapists use these formats to emphasize the importance of continuing to take medi- cations and to help patients solve the special family, social, school, and occupational problems caused by their disorder. Few controlled studies have tested the effectiveness of such adjunctive therapy, but those that have been done, along with numerous clini- cal reports, suggest that it helps reduce hospitalization, improves social functioning, and increases patients' ability to obtain and hold a job (Scott & Colom, 2005;Vieta, 2005).

Bipolcir Disorders

In bipolar disorders, episodes of mania alternate or intermix with episodes of de- pression. These disorders are much less common than unipolar depression. They may take the form of bipolar I, bipolar II, or cyclothymic disorder.

Mania may be related to high norepinephrine activity along with a low level of serotonin activity. Some researchers have also linked bipolar disorders to improper transport of ions back and forth between the outside and the inside of a neuron's membrane, others have focused on deficiencies of key proteins and other chemicals within certain neurons, and still others have uncovered abnormalities in key brain structures. Genetic studies suggest that people may inherit a predisposition to these biological abnormalities.

Lithium and other mood stabilizing drugs have proved to be very effective in reducing and preventing both the manic and the depressive episodes of bipolar dis- orders. These drugs may reduce bipolar symptoms by affecting the activity of second messengers or key proteins or other chemicals within certain neurons throughout the brain. Patients tend to fare better when antibipolar drugs and/or other psychotropic drugs are combined with adjunctive psychotherapy.

224 .//CHAPTER 7

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Bipolcir Disorders

224 .//CHAPTER 7

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Mood Disorders :// 225

PUTTING IT... together Making Sense of Al] That Is Known

During the past 40 years, researchers and clinicians have made tremendous gains in the understanding and treatment of mood disorders. Unipolar depression, for example, has become one of the most treatable of all psychological disorders. Cognitive therapy, interpersonal psychotherapy, and antidepressant drugs are all helpful in cases of any severity; couple therapy is helpful in select cases; ECT is useful in severe cases; some new biological treatments seem promising; and combinations of various approaches are sometimes more helpful than one approach alone.

During the same period of time, several factors have been tied closely to unipolar depression, including biological abnormalities, life stress, a reduction in positive rein- forcements, negative ways of thinking, a perception of helplessness, and sociocultural influences. Precisely how all of these factors relate to unipolar depression, however, is unclear. Several relationships are possible:

1. One or the factors may be the key cause of unipolar depression. If so, cognitive or biological factors seem to be leading candidates.

2. Different factors may be capable of initiating unipolar depression in different persons. Some people may, for example, begin with low serotonin activity, which predisposes them to react helplessly in stressful situations, interpret events negatively, and enjoy fewer pleasures in life. Others may first suffer a severe loss, which triggers helplessness reactions, low serotonin activity, and reductions in positive rewards.

3. An interaction between two or more specific factors may be necessary to produce unipolar depression (Klocek et al., 1997). Perhaps people will become de- pressed only if they have low levels of serotonin activity, feel helpless, and repeatedly blame themselves for negative events.

4. The various factors may play different roles in unipolar depression. Some may cause the disorder, some may result from it, and some may keep it going.

As with unipolar depression, clinicians and researchers have learned much about bipolar disorders during the past 40 years. But bipolar disorders appear to be best explained by a focus largely on one kind of variable—biological factors. The evidence suggests that biological abnormalities, perhaps inherited and perhaps triggered by life stress, cause bipolar disorders. In addition, the key focus of treatment for these disorders

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Mood Disorders :// 225

PUTTING IT... together Making Sense of Al] That Is Known

1. One or the factors may be the key cause of unipolar depression. If so, cognitive or biological factors seem to be leading candidates.

4. The various factors may play different roles in unipolar depression. Some may cause the disorder, some may result from it, and some may keep it going.

226 ://CHAPTER 7

is narrow and simple—lithium and/or other mood stabilizers, perhaps combined with other psychotropic drugs. Adjunctive psychotherapy may also be of significant help in cases of bipolar disorder.

There is no question that investigations into mood disorders have been fruitful, and valuable insights should continue to unfold in the years ahead. On the other hand, the sobering fact remains that one-third of people with a mood disorder do not improve under treatment and must suffer depression or manic episodes until they run their course. Now that clinical researchers have gathered so many important pieces of the puzzle, they must put the pieces together into a still more meaningful picture that will suggest even better ways to predict, prevent, and treat these disorders.

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• \\\ THOUqHTS ///

0. 1. Almost every day we experience ups and downs in mood. Flow can we distinguish the everyday blues from clinical depression? pp. 193- 198

2. In one study, students who listened to a sad song became more depressed than those who listened to a happy song (Stratton & Zalanowski, 1999, 1994). Yet the sad-song students reported "enjoying" their musical experience more than the happy-song students. What might be going on here? pp. 193-198

3. Many comedians report that they have grappled with depression.

— • -6 • • A/4, 6. 6,

• \\\ KEY TEPAPS/// #77: depression, p. 193

mania, p. 193

unipolar depression, p. 193

0: bipolar disorder, p. 193 molar depressive disorder, p. 197 dysthmic disorder, p. 197

reactive depression, p. 198

405:7: endogenous depression, p. 198

norepinephrine, p. 199

serotonin, p. 199

melatonin, p. 199

,for. seasonal affective disorder, p. 199

prefrontal cortex, p. 200

hippocampus, p. 200

Is there something about perform- ing that might improve their mood? Is there something about being depressed that might make them more skilled at thinking or acting funny? pp. 193-222, 223

4. Some people argue that antide- pressant drugs serve to curb useful behavior, destroy individuality, and blunt people's concerns about soci- etal ills. Are such concerns justified? pp. 201 -203

5. Several different kinds of theories keep pointing to the social sphere as a key factor in depression—for

amygdala, p. 200

Brodmann Area 25, p. 200

electroconvulsive therapy (ECT), p. 200

MAO inhibitors, p. 201

tyramine, p. 202

tricyclics, p. 202

selective serotonin reuptake inhibitors (SSR1s), p. 203

vagus nerve stimulation, p. 204

transcranial magnetic stimulation, p. 204

deep brain stimulation (DBS), p. 205

symbolic loss, p. 205

learned helplessness, p. 209

example, social loss, social ties, social rewards, and social attitudes. Why might problems in the social arena be particularly tied to depression? pp. 205-206, 208-210, 213-215

6. Friends and family members try, with limited success, to convince depressed people that their gloom- and-doom view of things is wrong. How does the successful cognitive approach to unipolar depression differ from such efforts at friendly persuasion? pp. 212-213

• •

attribution, p. 210

cognitive triad, p. 211

automatic thoughts, p. 211

rumination, pp. 211, 216

cognitive therapy, p. 212

interpersonal psychotherapy (IPT), p.214

couple therapy, p. 215

hypomanic episode, p. 219

bipolar 1 disorder, p. 219

biopolar 11 disorder, p. 219

cyclothymic disorder, p. 220

lithium, p. 222

second messengers, p. 224

226 ://CHAPTER 7

is narrow and simple—lithium and/or other mood stabilizers, perhaps combined with other psychotropic drugs. Adjunctive psychotherapy may also be of significant help in cases of bipolar disorder.

2,.•••••••,•-••••••••,••• •̀ ',:z.•/-P.V./VaC.;#•. ,

• \\\ THOUqHTS ///

0. 1. Almost every day we experience ups and downs in mood. Flow can we distinguish the everyday blues from clinical depression? pp. 193- 198

3. Many comedians report that they have grappled with depression.

— • -6 • • A/4, 6. 6,

• \\\ KEY TEPAPS/// #77: depression, p. 193

mania, p. 193

unipolar depression, p. 193

0: bipolar disorder, p. 193 molar depressive disorder, p. 197 dysthmic disorder, p. 197

reactive depression, p. 198

405:7: endogenous depression, p. 198

norepinephrine, p. 199

serotonin, p. 199

melatonin, p. 199

,for. seasonal affective disorder, p. 199

prefrontal cortex, p. 200

hippocampus, p. 200

Is there something about perform- ing that might improve their mood? Is there something about being depressed that might make them more skilled at thinking or acting funny? pp. 193-222, 223

4. Some people argue that antide- pressant drugs serve to curb useful behavior, destroy individuality, and blunt people's concerns about soci- etal ills. Are such concerns justified? pp. 201 -203

5. Several different kinds of theories keep pointing to the social sphere as a key factor in depression—for

amygdala, p. 200

Brodmann Area 25, p. 200

electroconvulsive therapy (ECT), p. 200

MAO inhibitors, p. 201

tyramine, p. 202

tricyclics, p. 202

selective serotonin reuptake inhibitors (SSR1s), p. 203

vagus nerve stimulation, p. 204

transcranial magnetic stimulation, p. 204

deep brain stimulation (DBS), p. 205

symbolic loss, p. 205

learned helplessness, p. 209

example, social loss, social ties, social rewards, and social attitudes. Why might problems in the social arena be particularly tied to depression? pp. 205-206, 208-210, 213-215

• •

attribution, p. 210

cognitive triad, p. 211

automatic thoughts, p. 211

rumination, pp. 211, 216

cognitive therapy, p. 212

interpersonal psychotherapy (IPT), p.214

couple therapy, p. 215

hypomanic episode, p. 219

bipolar 1 disorder, p. 219

biopolar 11 disorder, p. 219

cyclothymic disorder, p. 220

lithium, p. 222

second messengers, p. 224

Mood Disorders :11. 227

\\\ rili I i3K r)U 12 &/

7 6 6 6

1. What are the key symptoms of depression and mania? pp. 194- 198, 219-220

2. What is the difference between unipolar depression and bipolar disorder? p. 194

3. Describe the role of norepinephrine and serotonin in unipolar depression. p. 199

4. Describe Freud and Abraham's psychodynamic theory of

depression and the evidence that supports it. pp. 205-206

5. How do behaviorists describe the role of rewards in depression? pp. 208-209

6. How might learned helplessness be related to human depression? pp. 209-210

7. What kinds of negative thinking may lead to mood problems? pp. 210-212

8. How do sociocultural theorists account for unipolar depression? pp. 213-214, 215-217

9. What roles do biological and genetic factors seem to play in bipolar disorders? pp. 220-222

10. Discuss the leading treatments for unipolar depression and bipolar disorders. How effective are these various approaches? pp. 200-205, 206-208, 208-209, 212-213, 214-215, 217, 222-224

■

,J11.

'40

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A Chapter 7 Video Cases

Depression: A Pervasive Disorder 'Wire Mothers" and Attachment: Harlow's Monkeys Seeking Happiness: To Each His Own Cognitive Therapy in Action ECT: Effective and Frightening Light Therapy: Treating Seasonal Affective Disorder

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Mood Disorders :11. 227

\\\ rili I i3K r)U 12 &/

7 6 6 6

1. What are the key symptoms of depression and mania? pp. 194- 198, 219-220

2. What is the difference between unipolar depression and bipolar disorder? p. 194

3. Describe the role of norepinephrine and serotonin in unipolar depression. p. 199

4. Describe Freud and Abraham's psychodynamic theory of

depression and the evidence that supports it. pp. 205-206

5. How do behaviorists describe the role of rewards in depression? pp. 208-209

6. How might learned helplessness be related to human depression? pp. 209-210

7. What kinds of negative thinking may lead to mood problems? pp. 210-212

8. How do sociocultural theorists account for unipolar depression? pp. 213-214, 215-217

9. What roles do biological and genetic factors seem to play in bipolar disorders? pp. 220-222

10. Discuss the leading treatments for unipolar depression and bipolar disorders. How effective are these various approaches? pp. 200-205, 206-208, 208-209, 212-213, 214-215, 217, 222-224

■

,J11.

'40

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SUICIDE CHAPTER

he war in Iraq never ended for Jonathan Michael Boucher. Not when he flew home from Baghdad, not when he moved to Saratoga Springs for a fresh start and, especially, not when nighttime arrived.

- Tortured by what he saw as on 18-year-old Army private during the 2003 invasion and occupation, Boucher was diagnosed with post-traumatic stress disorder (PTSD) and honorably discharged from the military less than two years later.

On May 15 three days before his 24th birthday, the young veteran committed suicide in his apartment's bathroom, stunning friends and family . . There was no note. . .

Johnny Boucher joined the Army right after graduating from East Lyme High School in Connecti- cut in 2002 because he was emotionally moved by the Sept. 11, 2001, terrorist attacks. "He felt it was his duty to do what he could for America," his father, Steven Boucher, 50, said.

Shortly after enlisting, the 6-foot-2-inch soldier deployed with the "Wolf Pack"— 1 st Battalion, 41st Field Artillery—and fought his way north in Iraq. He landed with his unit at Baghdad In- ternational Airport and was responsible for helping guard it. The battalion earned a Presidential Unit Citation for "exceptional bravery and heroism in the liberation of Baghdad."

But it was during those early months of the war that Johnny Boucher had the evils of combat etched into his mind. The soldier was devastated by seeing a young Iraqi boy holding his dead father, who had been shot in the head. Later, near the airport, the soldier saw four good friends in his artillery battery killed in a vehicle accident minutes after one of them relieved him from duty, his father said.

Boucher tried to rescue the soldiers. Their deaths and other things his son saw deeply impacted his soul after he returned because he was sensitive about family and very patriotic, Steven Boucher said. . . .

But when the sun set, memories of combat and lost friends rose to the top, causing the for- mer artilleryman severe nightmares. Sometimes he would curl up in a ball and weep, causing his parents to try to comfort him. . . . 'At nighttime, he was just haunted," Steven Boucher said. . . "Haunted, 1 think, by war" Bitterness about the war had crept in, and the troubled former soldier started drinking to calm himself .

Supported by a huge family he adored ... Johnny Boucher recently got his own apartment on Franklin Street and appeared to be getting back on track. He seemed to be calm and enjoying life. But it was difficult to tell, and he was still fearful of sleep, his father said. They had plans for a hike, a birthday party and attending his brother Jeffrey's graduation. . . . Then, without warning, Johnny Boucher was gone. He hanged himself next to a Bible, his Army uniform and a garden statue of an angel, said his mother, who discovered him after he failed to show up to work for two days. . . .

Yiisko, 2008

Salmon spawn and then die, after an exhausting upstream swim to their breeding ground. Lemmings rush to the sea and drown. But only humans knowingly take their own lives.The actions of salmon and lemmings are instinctual responses that may even help their species survive in the long run. Only in the human act of suicide do beings act for the specific purpose of putting an end to their lives.

TOPIC OVERVIEW What Is Suicide? How Is Suicide Studied?

Patterns and Statistics

What Triggers a Suicide? Stressful Events and Situations Mood and Thought Changes

Alcohol and Other Drug Use

Mental Disorders

Modeling: The Contagion of Suicide

What Are the Underlying Causes of Suicide? The Psychodynamic View

Durkheim's Sociocultural View

The Biological View

Is Suicide Linked to Age? Children

Adolescents

The Elderly

Treatment and Suicide What Treatments Are Used after Suicide Attempts?

What Is Suicide Prevention?

Do Suicide Prevention Programs Work?

Putting It Together: Psychological and Biological Insights Lag Behind

SUICIDE CHAPTER

he war in Iraq never ended for Jonathan Michael Boucher. Not when he flew home from Baghdad, not when he moved to Saratoga Springs for a fresh start and, especially, not when nighttime arrived.

On May 15 three days before his 24th birthday, the young veteran committed suicide in his apartment's bathroom, stunning friends and family . . There was no note. . .

Yiisko, 2008

TOPIC OVERVIEW What Is Suicide? How Is Suicide Studied?

Patterns and Statistics

What Triggers a Suicide? Stressful Events and Situations Mood and Thought Changes

Alcohol and Other Drug Use

Mental Disorders

Modeling: The Contagion of Suicide

What Are the Underlying Causes of Suicide? The Psychodynamic View

Durkheim's Sociocultural View

The Biological View

Is Suicide Linked to Age? Children

Adolescents

The Elderly

Treatment and Suicide What Treatments Are Used after Suicide Attempts?

What Is Suicide Prevention?

Do Suicide Prevention Programs Work?

Putting It Together: Psychological and Biological Insights Lag Behind

oparasuicidecA suicide attempt that does not result in death.

esuicide0A self-inflicted death in which the person acts intentionally, directly, and consciously.

Suicide has been recorded throughout history. The Old Testament described King Saul's suicide:"There Saul took a sword and fell on it."The ancient Chinese, Greeks, and Romans also provided examples. In more recent times, twentieth-century suicides by such celebrated individuals as writer Ernest Hemingway, actress Marilyn Monroe, and rock star Kurt Cobain both shocked and fascinated the public. Even more disturbing are mass suicides such as those of the Heaven's Gate cult in 1997.

Before you finish reading this page, someone in the United States will try to kill himself. At least 60 Americans will have taken their own lives by this time tomorrow.... Many of those who attempted will try again, a number with lethal success.

(Shneidwan & Mandelkorn, 1983)

Today suicide is one of the leading causes of death in the world. It has been esti- mated that 700,000 or more people may die by it each year, more than 31,000 in the United States alone (Ohayon, 2009; Stolberg et al., 2002) (see Table 8-1). Millions of other people throughout the world-600,000 in the United States—make unsuccessful attempts to kill themselves; such attempts are called parasuicides. Actually, it is difficult to obtain accurate figures on suicide, and many investigators believe that estimates are often low. For one thing, suicide can be difficult to distinguish from unintentional drug overdoses, automobile crashes, drownings, and other accidents (Wertheimer, 2001; Lester, 2000). Many apparent "accidents" were probably intentional. For another, since suicide is frowned on in our society, relatives and friends often refuse to acknowledge that loved ones have taken their own lives.

Suicide is not classified as a mental disorder by DSM-IV-TR, but clinicians are aware of the high frequency with which psychological dysfunctioning—a breakdown of coping skills, emotional turmoil, a distorted view of life—plays a role in this act. Although suicide is frequently linked to depression, around half of all suicides result from other mental disorders, such as schizophrenia or alcohol dependence, or involve no clear psychological disorder at all (Maris, 2001). Jonathan Boucher, the young combat veteran about whom you read at the beginning of this chapter, had intense feelings of depression and devel- oped a severe drinking problem, but these symptoms and his act of suicide seemed to derive from the posttraumatic stress disorder that engulfed his life and functioning.

able:

Most Common Causes of Death in the United States

Rank Cause Deaths Per Year

Percentage of Total Deaths

1 Heart disease 696,947 28.5

2 Cancer 557,271 22.8

3 Stroke 162,672 6.7

4 Chronic respiratory diseases 124,816 5.1

5 Accidents 106,742 4.4

6 Diabetes 73,249 3.0

7 Pneumonia and influenza 65,681 2.7

8 Alzheimer's 58,866 2.4

9 Kidney disease 40,974 1.7

10 Septicemia 33,965 1.4

11 Suicide 31,655 1.3

Source: National Center for Health Statistics, National Vital Health Statistics Report (2005).

230 ://CHAPTER 8

oparasuicidecA suicide attempt that does not result in death.

esuicide0A self-inflicted death in which the person acts intentionally, directly, and consciously.

(Shneidwan & Mandelkorn, 1983)

able:

Most Common Causes of Death in the United States

Rank Cause Deaths Per Year

Percentage of Total Deaths

1 Heart disease 696,947 28.5

2 Cancer 557,271 22.8

3 Stroke 162,672 6.7

4 Chronic respiratory diseases 124,816 5.1

5 Accidents 106,742 4.4

6 Diabetes 73,249 3.0

7 Pneumonia and influenza 65,681 2.7

8 Alzheimer's 58,866 2.4

9 Kidney disease 40,974 1.7

10 Septicemia 33,965 1.4

11 Suicide 31,655 1.3

Source: National Center for Health Statistics, National Vital Health Statistics Report (2005).

230 ://CHAPTER 8

eft Behind

• • i • • . PI

I I

Suicide :11 231

41What Is Suicide? Not every self-inflicted death is a suicide. A man who crashes his car into a tree

after falling asleep at the steering wheel is not trying to kill himself. Thus Edwin

Shneidman (2005,1993, 1963), one of the most influential writers on this topic,

defines suicide as an intentioned death—a self-inflicted death in which one

makes an intentional, direct, and conscious effort to end one's life.

Intentioned deaths may take various forms. Consider the following ex-

amples. All three of these people intended to die, but their motives, concerns,

and actions differed greatly.

Dave was a successful man. By the age of 50 he had risen to the vice presidency of a small but profitable investment firm. He had a caring wife and two teenage sons who respected him. They lived in an upper-middle-class neighborhood, had a spacious house, and enjoyed a life of comfort.

In August of his fiftieth year, everything changed. Dave was fired. just like that. The economy had gone bad once again, the firm's profits were down and the firm's president wanted to try new, fresher investment strategies and marketing approaches. He wanted to try a younger person in Dave's position.

The experience of failure, loss, and emptiness was overwhelming for Dave. He looked for another position, but found only low-paying jobs for which he was overqualified. Each day as he looked for work Dave became more depressed, anxious, and desperate. He thought of trying to start his own investment company or to be a consultant of some kind, but, in the cold of night, he believed he was just fooling himself with such notions. He kept sinking, withdrew from others, and felt increasingly hopeless.

Six months after losing his job, Dave began to consider ending his life. The pain was too great, the humiliation unending. He hated the present and dreaded the future. Throughout February he went back and forth. On some days he was sure he wanted to die. On other days, an enjoyable evening or uplifting conversation might change his mind temporarily. On a Monday late in February he heard about a job possibility, and the anticipation of the next day's interview seemed to lift his spirits. But Tuesday's interview did not go well. It was clear to him that he would not be offered the job. He went home, took a recently pur- chased gun from his locked desk drawer, and shot himself

Demaine never truly recovered from his mother's death. He was only 7 years old and unprepared for such a loss. His father sent him to live with his grandparents for a time, to a new school with new kids and a new way of life. In Demaine's mind, all these changes were for the worse. He missed the joy and laughter of the past. He missed his home, his father, and his friends. Most of all he missed his mother.

He did not really understand her death. His father said that she was in heaven now, at peace, happy. Demaine's unhappiness and loneliness continued day after day and he began to put things together in his own way. He believed he would be happy again if he could join his mother. He felt she was waiting for him, waiting for him to come to her. These thoughts seemed so right to him; they brought him comfort and hope. One evening, shortly after saying good night to his grandparents, Demaine climbed out of bed, went up the stairs to the roof of their apartment house, and jumped to his death. In his mind he was joining his mother in heaven.

Tya and Noah had been going together for a year. It was Tya's first serious relationship; it was her whole life. Thus when Noah told her that he no longer loved her and was leaving her for someone else, she was shocked and shaken.

As the weeks went by, Tya was filled with two competing feelings—depression and anger. Several times she called Noah, begged him to reconsider, and pleaded for a chance to win him back. At the same time, she hated him for putting her through such misery.

_ AO 41 - ° 11. • •

eft Behind

• • i • • . PI

I I

Suicide :11 231

41What Is Suicide? Not every self-inflicted death is a suicide. A man who crashes his car into a tree

after falling asleep at the steering wheel is not trying to kill himself. Thus Edwin

Shneidman (2005,1993, 1963), one of the most influential writers on this topic,

defines suicide as an intentioned death—a self-inflicted death in which one

makes an intentional, direct, and conscious effort to end one's life.

Intentioned deaths may take various forms. Consider the following ex-

amples. All three of these people intended to die, but their motives, concerns,

and actions differed greatly.

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Murphy, 2005). Relatives, friends, therapists, or physicians may remember past statements, conversations, and behaviors that shed light on a suicide. Retrospec- tive information may also be provided by the suicide notes that some victims leave behind (Wong et al., 2009). However, such sources of information are not always available or reliable (Sudak et al., 2008). Around half of all suicide victims have never been in psychotherapy (Stolberg et al., 2002), and less than one-third leave notes (Maris, 2001).

Because of these limitations, many researchers also use a second strategy— studying people who survive their suicide attempts. It is estimated that there are 8 to 20 nonfatal suicide attempts for every fatal suicide (Maris, 2001). However, it may be that people who survive suicide differ in important ways from those who do not (Cutler et al., 2001). Many of them may not really have wanted to die, for example. Nevertheless, suicide researchers have found it useful to study survivors of suicide, and this chapter shall consider those who attempt suicide and those who commit suicide as more or less alike.

234 ://CHAPTER 8

kl The Private Dreams and

1.'Despair of a 111,otk Legend

Patterns and Statistics Suicide happens within a larger social setting, and researchers have gathered many statistics regarding the social contexts in which such deaths take place. They have found, for example, that suicide rates vary from country to country (Sadock & Sadock, 2007). Russia, Hungary, Germany, Austria, Finland, Den- mark, China, and Japan have very high rates, more than 20 suicides annually per 100,000 persons; conversely, Egypt, Mexico, Greece, and Spain have relatively low rates, fewer than 5 per 100,000. The United States and Canada fall in be-

tween, each with a suicide rate of around 12 per 100,000 persons; England has a rate of 9 per 100,000.

Religious affiliation and beliefs may help account for these national differences (Sadock & Sadock, 2007). For example, countries that are largely Catholic, Jewish, or Muslim tend to have low suicide rates. Perhaps in these countries, strict prohibitions against suicide or a strong religious tradition discourage many people from committing suicide (Stack & Kposowa, 2008).Yet there are exceptions to this rule. Austria, a largely Roman Catholic country, has one of the highest suicide rates in the world.

Research is beginning to suggest that religious affiliation may not help prevent sui- cide as much as the degree of an individual's devoutness. Regardless of their particular persuasion, very religious people seem less likely to commit suicide (Stack & Kposowa, 2008). Similarly, it seems that people who hold a greater reverence for life are less prone to consider or attempt self-destruction (Lee, 1985).

The suicide rates of men and women also differ (see Figure 8-1). Three times as many women attempt suicide as men, yet men succeed at more than three times the rate of women (Humphrey, 2006). Around the world 19 of every 100,000 men kill themselves each year; the suicide rate for women is 4 per 100,000 (Levi et al., 2003).

One reason for these differing rates appears to be the different methods used by men and women (Stack & Wasserman, 2009). Men tend to use more violent methods, such as shooting, stabbing, or hanging themselves, whereas women use less violent methods, such as drug overdose. Guns are used in nearly two-thirds of the male suicides in the United States, compared to 40 percent of the female suicides (Maris, 2001).

Suicide is also related to social support and marital status (Cutright et al., 2007). In one study, around half of the individuals who had committed suicide were found to have no close friends (Maris, 2001). Fewer still had close relationships with parents and other family members. In a related vein, research has revealed that divorced persons have a higher suicide rate than married or cohabitating individuals (Stolberg et al., 2002).

Finally, in the United States at least, suicide rates seem to vary according to race.The overall suicide rate of white Americans, 12 per 100,000 persons, is almost twice as high as that of African Americans, Hispanic Americans, and Asian Americans (Walker et al., 2008; Oquendo et al., 2005).A major exception to this pattern is the very high suicide

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234 ://CHAPTER 8

kl The Private Dreams and

1.'Despair of a 111,otk Legend

tween, each with a suicide rate of around 12 per 100,000 persons; England has a rate of 9 per 100,000.

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rate of Native Americans, which overall is one and a half times the national average (Hill, 2009). Altho ugh the extreme poverty of many Native Americans may partly explain this trend, studies show that factors such as alcohol use, modeling, and the availability of guns may also play a role (Goldston et al., 2008). Studies of Native Americans in Canada yield similar results (Matsumoto & _Nang, 2008).

Some of these statistics on suicide have been questioned (Leach & Leong, 2008). One analysis suggests that the actual rate of suicide may be 15 percent higher for African Americans and 6 percent higher for women than usually reported (Phillips & Ruth, 1993). People in these groups are more likely than others to use methods of suicide that can be mistaken for causes of accidental death, such as poisoning, drug overdose, single-car crashes, and pedestrian accidents.

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236 ://CHAPTER 8

Wheat Is Suicide?

Suicide is a self-inflicted death in which one makes an intentional, direct, and con- scious effort to end one's life. Four kinds of people who intentionally end their lives have been distinguished: the death seeker, the death initiator, the death ignorer, and the death darer. Two major strategies are used in the study of suicide: retrospective analysis and the study of people who survive suicide attempts.

Suicide ranks among the top causes of death in Western society. Rates vary from country to country. One reason seems to be cultural differences in religious affiliation, beliefs, or degree of devoutness. Suicide rates also vary according to race, gender, social support, and marital status.

day.Blues.....and .Sulade

4,What Triggers a Suicide? Suicidal acts may be connected to recent events or current conditions in a person's life. Although such factors may not be the basic motivation for the suicide, they can pre.- cipitate it. Common triggering factors include stressful events, mood and thought changes, alcohol and other drug use, mental disorders, and modeling.

Stressful Events and Situations Researchers have counted more stressful events in the recent lives of suicide attempters than in the lives of nonattempters (Kessler et al., 2008). At the beginning of this chapter, for example, you read about a young man who committed suicide upon returning to civilian life, after experiencing the enormous stress of combat in Iraq. However, the stressors that help lead to suicide do not need to be as horrific as those tied to combat. Common forms of immediate stress seen in cases of suicide are the loss of a loved one through death, divorce, or rejection (Ajdacic-Gross et al., 2008); loss of a job (Noh, 2009); and stress due to hurricanes or other natural disasters. People may also attempt suicide in response to long- term stressors rather than recent ones.Three such stressors are particularly common—serious illness, an abusive environment, and occupational stress.

Serious illness People whose illnesses cause them great pain or severe disability may try to commit suicide, believing that death is unavoidable and imminent (Schneider & Shenassa, 2008).They may also believe that the suffering and problems caused by their illnesses are more than they can endure. Studies suggest that as many as one-third of individuals who die by suicide have been in poor physical health during the months prior to their suicidal acts (Sadock & Sadock, 2007; Conwell et al., 1990).

Abusive Environment Victims of an abusive or repressive environ- ment from which they have little hope of escape sometimes commit suicide. For example, prisoners of war, inmates of concentration camps, abused spouses, abused children, and prison inmates have tried to end their lives (Lohner & Konrad, 2009; Konrad et al., 2007) (see Figure 8-2). Like those who have serious illnesses, these people may have felt that they could endure no more suffering and believed that there was no hope for improvement in their condition.

Occupation& Stress Some jobs create feelings of tension or dissat- isfaction that may trigger suicide attempts. Research has found particu- larly high suicide rates among psychiatrists and psychologists, physicians, nurses, dentists, lawyers, police officers, farmers, and unskilled laborers

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236 ://CHAPTER 8

Wheat Is Suicide?

day.Blues.....and .Sulade

experience mu tip e suict am t particurat risk_tor . stilf-

tniction. In 2005, Hunter S. Thorn neer of so-called gonko -journalis

author of Fear and Loathing in shot himself to death.

€,±rot Fri -

Suicide :1/ 237

(Sansone & Sansone, 2009; Tanner, 2008; Sadock & Sadock, 2007). Such findings do not necessarily mean that occupational pressures directly cause suicidal actions. Perhaps unskilled workers are responding to financial insecurity rather than job stress when they attempt suicide. Similarly, rather than reacting to the emotional strain of their work, sui- cidal psychiatrists and psychologists may have long-standing emotional problems that stimulated their career interest in the first place.

Mood and Thought Changes Many suicide attempts are preceded by a change in mood.The change may not be severe enough to call for a diagnosis of a mental disorder, but it does represent a significant shift from the person's past mood. The most common change is an increase in sadness. Also common are increases in feelings of anxiety, tension, frustration, anger, or shame (Fawcett, 2007; Werth, 2004). In fact, Shneidman (2005, 2001) suggests that the key to suicide is "psychache," a feeling of psychological pain that seems intolerable to the person. A recent study of 88 patients found that those who scored higher on a measure called the Psychological Pain Assessment Scale were indeed more likely than others to commit suicide (Pompili et al., 2008).

Suicide attempts may also be preceded by shifts in patterns of thinking. Individuals may become preoccupied with their problems, lose perspective, and see suicide as the only effective solution to their difficulties (Shneidman, 2005, 2001, 1987). They often develop a sense of hopelessness—a pessimistic belief that their present circumstances, problems, or mood will not change. Some clinicians believe that a feeling of hopelessness is the single most likely indicator of suicidal intent, and they take special care to look for signs of hopelessness when they assess the risk of suicide (Van Orden et al., 2008).

Many people who attempt suicide fall victim to dichotomous thinking, viewing problems and solutions in rigid either/or terms (Shneidman, 2005, 2001, 1993). Indeed, Shneidman has said that the "four-letter word" in suicide is "only," as in "suicide was the only thing I could do" (Mans, 2001). In the following statement a woman who survived her leap from a building describes her dichotomous thinking at the time. She saw death as the only alternative to her pain:

I was so desperate. I felt, my God, I couldn't face this thing. Everything was like a terrible whirlpool of con fusion. And I thought to myself There's only one thing to do. I just have to lose consciousness. That's the only way to get away from it. The only way to lose con- sciousness, I thought, was to jump off something good and high. . . .

(Shrieidnian, 1987, p. 56)

Alcohol and Other Drug Use Studies indicate that as many as 70 percent of the people who attempt suicide drink alcohol just before the act (Crosby et al., 2009; Lejoyeux et al., 2008; McCloud et al., 2004). Autopsies reveal that about one-fourth of these people are legally intoxicated (Flavin et al., 1990). It may be that the use of alcohol lowers the individuals' fears of committing suicide, releases underlying aggressive feelings, or impairs their judgment and problem-solving ability. Research shows that the use of other kinds of drugs may have a similar tie to suicide, particularly in teenagers and young adults (Darke et al., 2009, 2005; Lester, 2000). A high level of heroin, for example, was found in the blood of Kurt Cobain at the time of his suicide in 1994 (Colburn, 1996).

Mental Disorders Although people who attempt suicide may be troubled or anxious, they do not nec- essarily have a psychological disorder as defined in DSM-IV-TR. Nevertheless, the

ehopeiessnesseA pessimistic belief that one's present circumstances, problems, or mood will not change.

°dichotomous thinkingeViewing problems and solutions in rigid either/ or terms.

experience mu tip e suict am t particurat risk_tor . stilf-

tniction. In 2005, Hunter S. Thorn neer of so-called gonko -journalis

author of Fear and Loathing in shot himself to death.

€,±rot Fri -

Suicide :1/ 237

(Shrieidnian, 1987, p. 56)

Mental Disorders Although people who attempt suicide may be troubled or anxious, they do not nec- essarily have a psychological disorder as defined in DSM-IV-TR. Nevertheless, the

ehopeiessnesseA pessimistic belief that one's present circumstances, problems, or mood will not change.

°dichotomous thinkingeViewing problems and solutions in rigid either/ or terms.

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majority of all suicide attempters do display such a disorder (Berman, 2009; Tatarelli et al., 2007). Research suggests that as many as half of all suicide victims had been experiencing severe depression, 20 percent chronic alcoholism, and 10 percent schizophrenia. Correspondingly, as many as 15 percent of people with each of these disorders try to kill them- selves. People who are both depressed and dependent on alcohol seem particularly prone to suicidal impulses (Sadock & Sadock, 2007). It is also the case that many people with borderline personality disorder, a broad pattern that you will read about in Chapter 13, try to harm themselves or make suicidal gestures as part of their disorder (Weinberg & Malts- berger, 2007).The issues with which these individuals are grappling are often quite different from those of other suicidal persons and so will be examined in Chapter 13.

As you saw in Chapter 7, people with major depressive disorder often experience suicidal thoughts. One program in Sweden was able to reduce the community suicide rate by teaching physicians how to rec- ognize and treat depression at an early stage (Rihmer et al., 1995). Even when depressed people are showing improvements in mood, however, they may remain high suicide risks. In fact, among those who are se- verely depressed, the risk of suicide may actually increase as their mood improves and they have more energy to act on their suicidal wishes (Sadock & Sadock, 2007). Recall, for example, Jonathan Boucher, the

combat veteran whose case opened this chapter. Just prior to his suicide, he had seemed to be calm and enjoying life again, according to family members and friends.

Severe depression also may play a key role in suicide attempts by persons with serious physical illnesses (Werth, 2004). A study of 44 patients with terminal illnesses revealed that fewer than one-quarter of them had thoughts of suicide or wished for an early death and that those who did were all suffering from major depressive disorder (Brown et al., 1986).

A number of the people who drink alcohol or use drugs just before a suicide at- tempt actually have a long history of abusing such substances (Burr et al., 2009; Clay, 2009; Roy, 2009).The basis for the link between substance-related disorders and suicide is not clear. Perhaps the tragic lifestyle of many persons with these disorders or their sense of being hopelessly trapped by a substance leads to suicidal thinking. Alternatively, a third factor—psychological pain, for instance, or desperation—may cause both sub- stance abuse and suicidal thinking (Sher et al., 2005). Such people may be caught in a downward spiral: They are driven toward substance use by psychological pain or loss, only to find themselves caught in a pattern of substance abuse that aggravates rather than solves their problems (Maris, 2001).

People with schizophrenia, as you will see in Chapter 12, may hear voices that are not actually present (hallucinations) or hold beliefs that are clearly false and perhaps bizarre (delusions).The popular notion is that when such persons kill themselves, they must be responding to an imagined voice commanding them to do so or to a delu- sion that suicide is a grand and noble gesture. Research indicates, however, that suicides by people with schizophrenia more often reflect feelings of demoralization or fears of further mental deterioration (Helsel, 2008; Pompili & Lester, 2007). Many young and unemployed sufferers who have had relapses over several years come to believe that the disorder will forever disrupt their lives. Still others seem to be disheartened by their substandard living conditions. Suicide is the leading cause of premature death among people with schizophrenia (Pompili & Lester, 2007).

Modeling: The Contagion of Suicide It is not unusual for people, particularly teenagers, to try to commit suicide after ob- serving or reading about someone else who has done so (Feigelman & Gorman, 2008; Stack, 2005, 2003). Perhaps these people have been struggling with major problems and

238 ://CHAPTER 8

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combat veteran whose case opened this chapter. Just prior to his suicide, he had seemed to be calm and enjoying life again, according to family members and friends.

238 ://CHAPTER 8

Suicide :It 239

Abnormality and the Arts

Can „,.usic :aspire Euicide?

n 2008, a 13-year-old girl in Britain hanged herself (Woodward, 2008).

The cause, according to a coroner, was in large part her obsession with emo music, music that mixes a guitar-based sound, punk rock, and strong doses of emotional- ity ("emo" is short for "emotional hard- core"). The coroner pointed in particular to the music of the popular emo band My Chemical Romance, her favorite group. Friends reported at the inquest into her death that the suicide victim had previously discussed the "glamour of suicide" that at- tracted her to emo music and had posted a picture of an emo girl with bloody wrists online. The British press, in turn, described My Chemical Romance as a "suicide cult band," prompting the band to defend itself and emo music in general as "antisuicide" and filled with positive messages in its lyrics (Woodward, 2008).

This tragedy is hardly the first time that music has been blamed by the public for suicidal acts. In fact, over the years, music genres as varied as country, opera, heavy metal, and pop rock have been pointed to as negative influences, particularly on teenagers, that can lead to suicide attempts (Copley, 2008; Snipes & Maguire, 1995; Litman & Farberow, 1994; Stack et al., 1994; Stack & Gundlach, 1992; Wass et al, 1991). Little research has been con- ducted on this issue, and that which has been done fails to provide clear support for such claims. But the concerns go on. Indeed, such concerns helped lead to the current music rating system, which informs consumers (and their parents) about the kinds of language and themes that appear on the CDs or music downloads.

Two famous cases in the 1980s first brought this concern into public aware- ness. One involved the music of Ozzy Osbourne, leader of the band Black Sab- bath. In the early days of Black Sabbath, Osbourne and the band centered much of their music on psychological themes, and the band's music was even perceived by many as having a "satanic" bent.

Osbourne departed the band for a solo career between 1979 and the late

1990s. During this solo period, his music was blamed for three suicides. In 1984 a 19-year-old boy shot himself in the head while listening to Osbourne's song "Suicide Solution." A lawyer for the boy's family and lawyers for two other families whose children committed suicide claimed that the theme of the song encouraged suicide as an acceptable solution to one's problems. The lawyers also claimed that the song contained tones known as "hemisync" (a process that uses sound waves to influence an individual's mental state) and that these tones left the suicidal boys unable to resist what was being said in the song. Finally, the lawyers claimed that the song had subliminal lyrics—words sung much faster than the normal rate of speech and unrec- ognizable to first-time listeners. Suppos- edly, the subliminal lyrics in the song were "Why try, why try? Get the gun and try Shoot, Shoot, Shoot." Osbourne's lawyers rejected such claims, and the court agreed, dismissing all three cases by 1986.

A second famous case involved the music of the heavy metal band Judas Priest. In 1985 two boys died after shooting themselves in the head with a shotgun. The boys had been drunk and on drugs and shot themselves in a "suicide pact" after

listening to a Judas Priest album for hours. Lawyers for the boys' families claimed that Judas Priest's 1977 song "Better by You, Better Than Me" contained, when played backward, the subliminal message "Do it" as well as "Try suicide" and "Let's be dead." The band's lawyers countered that any song played backward might seem to have a hidden message. The trial judge agreed and dismissed the $6.2 million lawsuit in 1990. He ruled that even if the lyrics conveyed subliminal messages, such messages had been unintentional.

If the music in these cases did not itself lead to suicide, what did? A number of cli- nicians have argued that the individuals in these cases were probably suffering from several kinds of factors typically linked to suicide—depression, stress, drug misuse, and the like.

Of course, the dismissal of these suits did not put to rest the concerns of parents, and in fact such concerns grow still greater whenever parents read about a teenager— like the 13-year-old in Britain—who com- mits suicide while listening to death-themed music. While such events are not common in our society, they do, sadly, occur on occasion.

Suicide :It 239

Abnormality and the Arts

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n 2008, a 13-year-old girl in Britain hanged herself (Woodward, 2008).

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the other person's suicide seems to reveal a possible solution, or perhaps they have been thinking about suicide and the other person's suicide seems to give them permission or finally persuades them to act. Either way, one suicidal act apparently serves as a model for another. Suicides by celebrities, other highly publicized suicides, and suicides by co- workers or colleagues are particularly common triggers.

Celebrities Research suggests that suicides by entertainers, political figures, and other well-known persons are regularly followed by unusual increases in the number of suicides across the nation (Fu &Yip, 2009; Stack, 2005,1987). During the week after the suicide of Marilyn Monroe in 1963, for example, the national suicide rate rose 12 percent (Phillips, 1974).

Other Highly Publicized Cases Suicides with bizarre or unusual aspects often receive intense coverage by the news media (Blood et al., 2007). Such highly publicized accounts may lead to similar suicides (Gould et al., 2007). During the year after a widely publicized, politically motivated suicide by self-burning in England, for example, 82 other people set themselves on fire, with equally fatal results (Ashton & Donnan, 1981). Inquest reports revealed that most of those people had histories of emotional problems and that none of the suicides had the political motivation of the publicized suicide.The imitators seemed to be responding to their own problems in a manner triggered by the suicide they had observed or read about.

Some clinicians argue that more responsible reporting could reduce this frighten- ing impact of highly publicized suicides (Blood et al., 2007; Gould et al., 2007). A careful approach to reporting was seen in the media's coverage of the suicide of Kurt Cobain. MTV's repeated theme on the evening of the suicide was "Don't do it!" In fact, thousands of young people called MTV and other radio and television stations in the hours after Cobain's death, upset, frightened, and in some cases suicidal. Some of the stations responded by posting the phone numbers of suicide prevention cen- ters, presenting interviews with suicide experts, and offering counseling and advice directly to callers. Perhaps because of such efforts, the usual rate of suicide both in Seattle, Cobain's hometown, and elsewhere held steady during the weeks that followed (Colburn, 1996).

Co-workers and Colleagues The word-of-mouth publicity that attends sui- cides in a school, workplace, or small community may trigger suicide attempts. The suicide of a recruit at a U.S. Navy training school, for example, was followed within

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two weeks by another and also by an attempted suicide at the school. To head off what threatened to become a suicide epidemic, the school began a program of staff education on suicide and group therapy sessions for recruits who had been close to the suicide victims (Grigg, 1988).The kinds of postsuicide programs put into action by this school and by MTV in the aftermath of Kurt Cobain's death are often referred to by clinicians as postvention.

has Triggers a Suicide?

Many suicidal acts are triggered by the current events or conditions in a person's

life. The acts may be triggered by recent stressors, such as loss of a loved one and

job loss, or long-term stressors, such as serious illness, an abusive environment, and

job stress. They may also be preceded by changes in mood or thought, particularly

increases in one's sense of hopelessness. In addition, the use of alcohol or other

kinds of substances, mental disorders, or news of another's suicide may precede

suicide attempts.

OWhat Are the Underlying Causes of Suicide? Most people faced with difficult situations never try to kill themselves. In an effort to understand why some people are more prone to suicide than others, theorists have pro- posed more basic explanations for self-destructive actions than the immediate triggers considered in the previous section.The leading theories come from the psychodynamic, sociocultural, and biological perspectives. As a group, however, these hypotheses have received limited research support and fail to address the full range of suicidal acts.Thus the clinical field currently lacks a satisfactory understanding of suicide.

The Psychodynamic View Many psychodynamic theorists believe that suicide results from depression and from anger at others that is redirected toward oneself.This theory was first stated by physician and psychologist Wilhelm Stekel at a meeting in Vienna in 1910, when he proclaimed that "no one kills himself who has not wanted to kill another or at least wished the death of another" (Shneidman, 1979). Agreeing with this notion, the influential psychiatrist Karl Menninger later called suicide "murder in the 180th degree."

As you read in Chapter 7, Freud (1917) and Abraham (1916, 1911) proposed that when people experience the real or symbolic loss of a loved one, they unconsciously incorporate the person into their own identity and feel toward themselves as they had felt toward the other. For a short while, negative feelings toward the lost loved one are experienced as self-hatred. Anger toward the loved one may turn into intense anger against oneself and finally into depression. Suicide is thought to be an extreme expres- sion of this self-hatred.The following description of a suicidal patient demonstrates how such forces may operate:

A 27-year-old conscientious and responsible woman took a knife to her wrists to punish herself for being tyrannical, unreliable, self-centered, and abusive. She was perplexed and frightened by this uncharacteristic self-destructive episode and was enormously relieved when her therapist pointed out that her invective described her recently deceased father much better than it did herself

(Gill, 1982, p. 15)

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has Triggers a Suicide?

Many suicidal acts are triggered by the current events or conditions in a person's

life. The acts may be triggered by recent stressors, such as loss of a loved one and

job loss, or long-term stressors, such as serious illness, an abusive environment, and

job stress. They may also be preceded by changes in mood or thought, particularly

increases in one's sense of hopelessness. In addition, the use of alcohol or other

kinds of substances, mental disorders, or news of another's suicide may precede

suicide attempts.

(Gill, 1982, p. 15)

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In support of Freud's view, researchers have often found a relationship between childhood losses—real or symbolic—and later suicidal behaviors (Ehnvall et al., 2008; Read et al., 2001).A classic study of 200 family histories, for example, found that early parental loss was much more common among suicide attempters (48 percent) than among nonsuicidal individuals (24 percent) (Adam et al., 1982). Common forms of loss were death of the father and divorce or separation of the parents. Similarly, a recent study of 343 depressed individuals found that those who had felt rejected or neglected as children by their parents were more likely than other individuals to attempt suicide as adults (Ehnvall et al., 2008).

Late in his career, Freud proposed that human beings have a basic "death instinct." He called this instinct Thanatos and said that it opposes the "life instinct."According to Freud, while most people learn to redirect their death instinct by aiming it toward oth- ers, suicidal people, caught in a web of self-anger, direct it squarely toward themselves.

Sociological findings are consistent with this explanation of suicide. National suicide rates have been found to drop in times of war (Maris, 2001), when, one could argue, people are encouraged to direct their self-destructive energy against "the enemy." In addition, in many parts of the world, societies with high rates of homicide tend to have low rates of suicide, and vice versa (Bills & Li, 2005). However, research has failed to establish that suicidal people are in fact dominated by intense feelings of anger. Although hostility is an important element in some suicides (Sher et al., 2005), several studies find that other emotional states are even more common (Castrogiovanni et al., 1998).

By the end of his career, Freud himself expressed dissatisfaction with his theory of suicide. Other psychodynamic theorists have also challenged his ideas over the years, yet themes of loss and self-directed aggression generally remain at the center of most psychodynamic explanations (King, 2003).

Durkheim's Sociocultural View Toward the end of the nineteenth century, Emile Durkheim (1897), a sociologist, developed a broad theory of suicidal behavior. Today this theory continues to be in- fluential and is often supported by research (Fernquist, 2007). According to Durkheim,

the probability of suicide is determined by how attached a person is to such social groups as the family, religious institutions, and community. The more thoroughly a person belongs, the lower the risk of suicide. Conversely, people who have poor relationships with their society are at greater risk of killing themselves. He defined several categories of suicide, including egoistic, altruistic, and anomic suicide.

Egoistic suicides are committed by people over whom society has little or no control.These people are not concerned with the norms or rules of society, nor are they integrated into the social fabric. According to Durkheim, this kind of suicide is more likely in people who are isolated, alienated, and nonreligious. The larger the number of such people living in a society, the higher that society's suicide rate.

Altruistic suicides, in contrast, are committed by people who are so well in- tegrated into the social structure that they intentionally sacrifice their lives for its well-being. Soldiers who threw themselves on top of a live grenade to save others, Japanese kamikaze pilots who crashed their planes into enemy ships during World War II, and Buddhist monks and nuns who protested the Vietnam War by setting themselves on fire may have been committing altruistic suicide (Leenaars, 2004; Stack, 2004). According to Durkheim, societies that encourage people to sacrifice themselves for others and to preserve their own honor (as Far Eastern societies do) are likely to have higher suicide rates.

Anomic suicides, another category proposed by Durkheim, are those com- mitted by people whose social environment fails to provide stable structures, such as family and religion, to support and give meaning to life. Such a societal condition, called anomie (literally, "without law"), leaves individuals without a

242 :IICHAPTER 8

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sense of belonging. Unlike egoistic suicide, which is the act of a person who rejects the structures of a society, anomie suicide is the act of a person who has been let down by a disorganized, inadequate, often decaying society.

Durkheim argued that when societies go through periods of anomie, their suicide rates increase. Historical trends support this claim. Periods of economic depression may bring about some degree of anomie in a country, and national suicide rates tend to rise during such times (Noll, 2009; Maris, 2001). Peri- ods of population change and increased immigration, too, tend to bring about a state of anomie, and again suicide rates rise (Kposowa et al., 2008).

A major change in an individual's immediate surroundings, rather than general societal problems, can also lead to anomic suicide. People who suddenly inherit a great deal of money, for example, may go through a period of anomie as their relation- ships with social, economic, and occupational structures are changed. Thus Durkheim predicted that societies with greater opportunities for change in individual wealth or status would have higher suicide rates, and this prediction, too, is supported by research (Cutright & Fernquist, 2001; Lester, 2000, 1985).

Although today's sociocultural theorists do not always em- brace Durkheim's particular ideas, most agree that social struc- ture and cultural stress often play major roles in suicide. In fact, the sociocultural view pervades the study of suicide. Recall the earlier discussion of the many studies linking suicide to broad factors such as religious affiliation, marital status, gender, race, and societal stress.You will also see the impact of such factors when you read about the ties between suicide and age.

Despite the influence of sociocultural theories such as Durkheim's, these theories cannot by themselves explain why some people who experi- ence particular societal pressures commit suicide while the majority do not. Durkheim himself concluded that the final explanation probably lies in the interaction between societal and individual factors.

The Biological View For years biological researchers relied largely on family pedigree studies to support their position that biological factors contribute to suicidal behavior. They repeatedly have found higher rates of suicide among the parents and close relatives of suicidal people than among those of nonsuicidal people (Bronisch & Lieb, 2008; Mittendorfer-Rutz et al., 2008). Such findings may suggest that genetic, and so biological, factors are at work.

In the past two decades, laboratory research has offered more direct support for a biological view of suicide. The activity level of the neurotransmitter serotonin has often been found to be low in people who commit suicide (Mann & Currier, 2007; Chen et al., 2005). An early hint of this relationship came from a study by psychiatric re- searcher Marie Asberg and her colleagues (1976).They studied 68 depressed patients and found that 20 of the patients had particularly low levels of serotonin activity. It turned out that 40 percent of the low-serotonin research participants attempted suicide, com- pared with 15 percent of the higher-serotonin participants. The researchers interpreted this to mean that low serotonin activity may be "a predictor of suicidal acts." Later stud- ies found that suicide attempters with low serotonin activity are 10 times more likely to make a repeat attempt and succeed than are suicide attempters with higher serotonin activity (Roy, 1992). Studies that examine the autopsied brains of suicide victims and PET scan studies of suicide attempters point in the same direction (Mann & Currier, 2007; Stanley et al., 2000, 1986, 1982).

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At first glance, these and related studies may appear to tell us only that depressed people often attempt suicide. After all, depression is itself related to low serotonin activ- ity. On the other hand, there is evidence of low serotonin activity even among suicidal individuals who have no history of depression (Mann & Currier, 2007). That is, low serotonin activity also seems to play a role in suicide separate from depression.

How, then, might low serotonin activity increase the likelihood of suicidal behavior? One possibility is that it contributes to aggressive and impulsive behaviors. It has been found, for example, that serotonin activity is lower in aggressive men than in nonaggres- sive men and that serotonin activity is often low in those who commit such aggressive acts as arson and murder (Oquendo et al., 2006, 2004; Stanley et al., 2000). Moreover, PET scan studies of people who are aggressive and impulsive (but not necessarily depressed) reveal abnormal activity in the serotonin-rich areas of the brain (Mann & Currier, 2007; New et al., 2004, 2002). Such findings suggest that low serotonin activity helps produce aggressive feelings and impulsive behavior. In people who are clinically depressed, low serotonin activity may produce aggressive tendencies that cause them to be particularly vulnerable to suicidal thoughts and acts. Even in the absence of a depres- sive disorder, however, people with low serotonin activity may develop such aggressive feelings that they, too, are dangerous to themselves or to others.

What Are the Undedying Causes of Suicide?

The leading explanations for suicide come from the psychodynamic, sociocultural, and biological models. Each has received only limited support. Psychodynamic theorists believe that suicide usually results from depression and self-directed anger. Emile Durkheim's sociocultural theory defines three categories of suicide based on the person's relationship with society: egoistic, altruistic, and anomic suicides. And biological theorists suggest that the activity of the neurotransmitter serotonin is par- ticularly low in individuals who commit suicide.

*is Suicide Linked to Age? The likelihood of committing suicide generally increases with age, although people of all ages may try to kill themselves. Currently, 1 of every 100,000 children in the United States (age 10 to 14) kills himself or herself each year, compared to 7.3 of every 100,000 teenagers, 12.1 of every 100,000 young adults, 16.6 of every 100,000 middle- aged adults, and 19 of every 100,000 persons over age 65 (CDC, 2008; Cohen, 2008; NAHIC, 2006). Clinicians have paid particular attention to self-destructive behavior in three age groups: children, adolescents, and the elderly. Although the features and theories of suicide discussed throughout this chapter apply to all age groups, each group faces unique problems that may play key roles in the suicidal acts of its members.

Children Although suicide is infrequent among children, it has been increasing over the past several decades (Dervic, Brent, & Oquendo, 2008). Indeed, more than 6 percent of all deaths among children between the ages of 10 and 14 years are caused by suicide (Arias et al., 2003). Boys outnumber girls by as much as 5 to 1. In addition, it has been estimated that 1 of every 100 children tries to harm himself or herself, and many thou- sands of children are hospitalized each year for deliberately self-destructive acts, such as stabbing, cutting, burning, overdosing, jumping from high places, or shooting themselves (Fortune & Hawton, 2007; Cytryn & McKnew, 1996).

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What Are the Undedying Causes of Suicide?

Suicide :1/ 245

Researchers have found that suicide attempts by the very young are commonly preceded by such behavioral patterns as running away from home; accident-proneness; aggressive acting out; temper tantrums; self-criticism; social withdrawal and loneliness; extreme sensitivity to criticism by others; low tolerance of frustration; dark fantasies, daydreams, or hallucinations; marked personality change; and overwhelming interest in death and suicide (Dervic et al., 2008; Cytryn & McKnew, 1996). Studies further have linked child suicides to the recent or anticipated loss of a loved one, family stress and a parent's unemployment, abuse by parents, and a clinical level of depression (Renaud et al., 2008;Van Orden et al., 2008).

Most people find it hard to believe that children fully comprehend the meaning of a suicidal act. They argue that because a child's thinking is so limited, children who attempt suicide fall into Shneidman's category of "death ignorers," like Demaine, who sought to join his mother in heaven. Many child suicides, however, appear to be based on a clear understanding of death and on a clear wish to die (Pfeffer, 2003). In addition, suicidal thinking among even normal children is apparently more common than most people once believed (Kovacs et al., 1993). Clinical interviews with schoolchildren have revealed that between 6 and 33 percent have thought about suicide (Riesch et al., 2008; Culp, Clyman, & Culp, 1995).

Adolescents

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Dear Mom, Dad, and everyone else, I'm sorry for what I've done, but I loved you all and I always will, for eternity. Please,

please, please don't blame it on yourselves. it was all my fault and not yours or anyone else's. If I didn't do this now, I would have done it later anyway. We all die some day, I just died sooner.

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(Berman, 1986)

The suicide ofJohn, age 17, was not an unusual occurrence. Suicidal actions become much more common after the age of 14 than at any earlier age. According to official records, overall 1,500 teenagers (age 15 to 19), or 7 of every 100,000, commit suicide in the United States each year (Van Orden et al., 2008). In addi- tion, at least 1 in 12 teenagers make suicide attempts and 1 in 6 think about suicide each year (Goldston et al., 2008). Because fatal illnesses are uncommon among the young, suicide has become the third leading cause of death in this age group, after accidents and homicides (Shain, 2007). About half of teenage suicides, like those of people in other age groups, have been tied to clinical depression, low self-esteem, and feelings of hopelessness, but many teenagers who try to kill themselves also appear to struggle with anger and impulsiveness or to have serious alcohol or drug problems (Renaud et al., 2008; Witte et al., 2008). In addition, some have deficiencies in their ability to sort out and solve problems (Brent, 2001).

Teenagers who consider or attempt suicide are often under great stress. They may experience long-term pressures such as poor (or missing) relationships with parents, family conflict, inadequate peer relationships, and social isolation (Capuzzi & Gross, 2008; Apter &Wasserman, 2007). Alternatively, their ac- tions also m.ay be triggered by more immediate stress, such as a parent's unemployment or medical illness, financial setbacks

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for the family, or a break-up with a boyfriend or girlfriend (Orbach & Iohan, 2007). Stress at school seems to be a particularly common problem for teenagers who attempt suicide. Some have trouble keeping up at school, while others may be high achievers who feel pressured to be perfect and to stay at the top of the class (Ho et al., 1995; Delisle, 1986).

Some theorists believe that the period of adolescence itself produces a stressful climate in which suicidal actions are more likely (King & Apter, 2003). Adolescence is a period of rapid growth that is often marked by conflicts, depressed feelings, ten- sions, and difficulties at home and school. Adolescents tend to react to events more sensitively, angrily, dramatically, and impulsively than individuals in other age groups; thus the likelihood of suicidal acts during times of stress is increased (Greening et al.

• • •

CLOSER OOK

The Black Box Controversy: Do Antidepressants Cause Suicide?

major controversy in the clinical field is whether antidepressant drugs are

highly dangerous for depressed children and teenagers. Throughout the 1990s, most psychiatrists believed that antidepres- sants—particularly the second-generation antidepressants—were safe and effective for children and adolescents, just as they seemed to be for adults, and they pre- scribed those medications readily (Kutcher & Gardner, 2008). However, after review- ing a large number of clinical reports and studying 3,300 patients on antidepres- sants, the United States Food and Drug Ad- ministration (FDA) concluded in 2004 that the drugs produce a red, though small, increase in the risk of suicidal behavior for certain children and adolescents, espe- cially during the first few months of treat- ment, and it ordered that all antidepressant containers carry "black box" warnings stating that the drugs "increase the risk of suicidal thinking and behavior in children." In 2007 the FDA expanded this warning to include young adults (Howland, 2008).

Although many clinicians have been pleased by the FDA order, others worry that it may be ill-advised (Brent, 2009). They argue that while the drugs may in- deed increase the risk of suicidal thoughts and attempts in as many as 2 to 3 percent of young patients, the risk of suicide is actually reduced in the vast majority of depressed children and teenagers who take the drugs (Kutcher & Gardner, 2008). To support this argument, they point out that the overall rate of teenage suicides decreased by 30 percent in the decade lead ing up to 2004, as the number of

antidepressant prescriptions provided to children and teenagers were soaring.

The critics of the black box warnings also point to the initial effect that the warn- ings hod on prescription patterns and teenage suicide rates in the United States and other countries. Some studies suggest that during the first two years following the institution of the black box warnings, the number of antidepressant prescriptions fell 22 percent in the United States while the rate of teenage suicide rose 14 percent in the United States, the largest suicide rate increase since 1979 (Fawcett, 2007). Al- though other studies challenge these num- bers (Wheeler et al., 20081, it is certainly possible that black box warnings were indirectly depriving many young patients of a medication that they truly needed to

help fight depression and head off suicide. Antidepressant prescriptions for depressed teenagers now seem to be rising again, and the effect of this trend reversal on teen- age suicide rates certainly awaits careful observation.

A major outgrowth and benefit of the black box controversy is that the FDA re- cently has expanded its interest in suicidal side effects to drugs other than antidepres- sants. It now requires pharmaceutical companies to test for suicidal side effects in certain newly developed drugs such as those for obesity and epilepsy before such drugs receive FDA approval (Carey, 2008; Harris, 2008). In the past, lethal effects of this kind never came to light until well after drugs had been approved and used by millions of patients.

246 ://CHAPTER 8

• • •

CLOSER OOK

The Black Box Controversy: Do Antidepressants Cause Suicide?

major controversy in the clinical field is whether antidepressant drugs are

antidepressant prescriptions provided to children and teenagers were soaring.

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2008). Finally, the suggestibility of adolescents and their eagerness to imitate others, including others who attempt suicide, may set the stage for suicidal action (Apter & Wasserman, 2007). One study found that 93 percent of adolescent suicide attempters had known someone who had attempted suicide (Conrad, 1992).

Teen Suicides: Aitempts versus Completions Far more teenagers attempt suicide than actually kill themselves—the ratio may be as high as 200 to 1.The unusually large number of unsuccessful suicides may mean that teenagers are less certain than older persons who make such attempts.While some do indeed wish to die, many may simply want to make others understand how desperate they are, get help, or teach others a lesson (Apter &Wasserman, 2007; Leenaars et al., 2001). Up to half of teenage attempters make new suicide attempts in the future, and as many as 14 percent eventually die by suicide (Wong et al. , 2008; Borowsky et al., 2001).

Why is the rate of suicide attempts so high among teenagers (as well as among young adults)? Several explanations, most pointing to societal factors, have been proposed. First, as the number and proportion of teenagers and young adults in the general popula- tion have risen, the competition for jobs, college admissions, and academic and athletic honors has intensified for them, leading increasingly to shattered dreams and ambitions (Holinger ,Sz Offer, 1993, 1991, 1982). Other explanations point to weakening ties in the family ( -which may produce feelings of alienation and rejection in many of today's young people) and to the easy availability of alcohol and other drugs and the pressure to use them among teenagers and young adults (Brent, 2001; Cutler et al., 2001).

The mass media coverage of suicides by teenagers and young adults may also con- tribute to the high rate of suicide attempts among the young (Apter & Wasserman, 2007; Gould et al., 2007). The detailed descriptions of teenage suicide that the media and the arts often offer may serve as models for young people who are contemplating suicide (Cheng et al., 2007; Wertheimer, 2001). In one of the most famous examples of this phenomenon, just days after the highly publicized suicides of four adolescents in a New Jersey town in 1987, dozens of teenagers across the United States took similar actions (at least 12 of them fatal)—two in the same garage just one week later. Similarly, one study found that the rate of adolescent suicide rose about 7 percent in New York City during the week following a television film on suicide, in contrast to a 0.5 percent increase in the adult suicide rate during the same week (Maris, 2001).

Teen Suicides: Multicultural issues Teenage suicide rates vary by ethnicity in the United States. Around 7.5 of every 100,000 white American teenagers commit suicide each year, compared to 5 of every 100,000 African American and Hispanic American teens (Goldston et al., 2008; NAHIC, 2006). Although these numbers certainly indicate that white American teens are more prone to suicide, the rates of the three groups are in fact becoming closer.The white American rate was 150 percent greater than the African American and Hispanic American rates in 1980; today it is only 50 percent greater.This closing trend may reflect increasingly similar pressures on young African, Hispanic, and white Americans—competition for grades and college opportunities, for example, is now intense for all three groups. The growing suicide rates for young African and Hispanic Americans may also be linked to rising unemployment among them, the many anxieties and economic pressures of inner-city life, and the rage felt by many of them over racial inequities and discrimination in our society (Duarte-Velez & Bernal, 2008; Goldston et al., 2008) Recent studies further indicate that 4.5 of every 100,000 Asian American teens now commit suicide each year.

The highest teenage suicide rate of all is displayed by Native Americans. Currently, more than 15 of every 100,000 Native American teenagers commit suicide each year, double the rate of white American teenagers and triple that of other minority teenagers. Clinical theorists attribute this extraordinarily high rate to factors such as the extreme poverty faced by most Native American teens, their limited educational and employment opportunities, their particularly high rate of alcohol abuse, and the geographical isolation experienced by those who live on reservations (Alcantara & Gone, 2008; Goldston et al., 2008). In addition, it appears that certain Native American reservations have extreme

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248 .,C/CHAPTER

suicide rates—called cluster suicides—and that teenagers who live in such communities are especially likely to be exposed to suicide, to have their lives disrupted, to observe suicidal models, and to be at risk for suicide contagion (Bender, 2006; Chekki, 2004).

The Elderly In Western society the elderly are more likely to commit suicide than people in any other age group. About 19 of every 100,000 persons over the age of 65 in the United States commit suicide. Elderly persons commit over 19 percent of all suicides in the United States, yet they account for only 12 percent of the total population.

Many factors contribute to this high suicide rate (Vannoy et al., 2007). As people grow older, all too often they become ill, lose close friends and relatives, lose control over their lives, and lose status in our society. Such experiences may result in feelings of hopelessness, loneliness, depression, or inevitability among aged persons and so increase the likelihood that they will attempt suicide. One study found that two-thirds of elderly individuals (above 80 years old) who committed suicide had experienced a medical hospitalization within two years preceding the suicide (Erlangsen et al., 2005). Other research reveals that the suicide rate of elderly people who have recently lost a spouse is particularly high (Ajdacic-Gross et al., 2008).And in one investigation, 44 percent of elderly people who committed suicide gave some indication that their act was prompted by the fear of being placed in a nursing home (Loebel et al., 1991).

Elderly persons are typically more determined than younger persons in their deci- sion to die and give fewer warnings, so their success rate is much higher (Woods, 2008). Apparently 1 of every 4 elderly persons who attempts suicide succeeds. Given the de- termined thinking of aged persons and their physical decline, some people argue that older persons who want to die should be allowed to cany out their wishes. However, clinical depression appears to play an important role in as many as 60 percent of suicides by the elderly, suggesting that more elderly persons who are suicidal should be receiving treatment for their depressive disorders (Hirsch et al., 2009; Awata et al., 2005).

The suicide rate among the elderly in the United States is lower in some minority groups (Alcantara & Gone, 2008; Leach & Leong, 2008; Utsey et al., 2008). Although Native Americans have the highest overall suicide rate, for example, the rate among elderly Native Americans is relatively low. The aged are held in high esteem by Native Americans and are looked to for the wisdom and experience they have acquired over the years, and this may help account for their low suicide rate. Such high regard is in sharp contrast to the loss of status often experienced by elderly white Americans.

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248 .,C/CHAPTER

Suicide :1/ 249

•

The kir- ht tr- Commit Suicide

In the foil of 1989, a Michigan doctor, Jack Kevorkian, built a "suicide device." A person using it could, at the touch of a button, change a saline solution being fed intravenously into the arm to one containing chemicals that would bring unconsciousness and a swift death. The following June, under the doctor's supervision, Mrs. J. Adkins took her life. She left a note explaining: "This is a decision taken in a normal state of mind and is fully considered. l have Alzheimer's disease and I do not want to let it progress any further. I do not want to put my family or myself through the agony of this terrible disease." Mrs. Adkins believed that she had a right to choose death. Michigan authorities promptly prohibited further use of Kevorkion's device, but the physician con- tinued to assist in the suicides of medically ill persons throughout the 1990s.

(ADAPTED FROM ORKIN, 1990; MALCOLM, 19901

n 1999 Dr. Kevorkian was convicted

of second-degree murder and sen-

tenced to prison for an assisted suicide

that he had conducted, filmed, and aired

on the television news show 60 Minutes. He was released From prison on parole

in 2007. However, his many court battles

have helped bring an important question to

the public's attention: Do individuals have

a right to commit suicide, or does society

have the right to stop them (Dickens et al.,

2008)?

The ancient Greeks valued physical and

mental well-being in life and dignity in death.

Therefore, individuals with a grave illness or

mental anguish were permitted to commit sui-

cide. Citizens could obtain official permission

from the Senate to take their own lives, and

judges were allowed to give them hemlock

(Humphry & Wickett, 1986).

Western traditions, in contrast, discour-

age suicide, on the basis of belief in the

"sanctity of life" (Dickens et al., 2008;

Eser, 1981). People in Western cultures

speak of "committing" suicide, as though

it were a criminal act (Sharma, 2009),

and allow the state to use force, including

involuntary commitment to a mental hos-

pital, to prevent it. But times and attitudes

are changing. Today the ideas of a "right

to suicide" and "rational suicide" are re-

ceiving more support from the public and

from many psychotherapists and physicians

(Curlin et al., 2008).

Public support for a right to suicide

seems strongest in connection with great

pain and terminal illness (Werth, 2004,

2000). Surveys show that more than two-

thirds of all Americans believe that termi-

nally ill persons should be free to take their

lives or to seek a physician's assistance to

do so (Harris Poll, 2005). In line with this

belief, the state of Oregon in 1997 passed

the "Death with Dignity" Act, allowing a

doctor to assist a suicide (by administering

a lethal dose of drugs) if two physicians

determine that the patient has less than six

months to live and is not basing the deci-

sion to die on depression or another men-

tal disorder. More than 400 people have

used this law to end their lives since 1997,

an average of 32 each year (Hoffman,

2007). Most of these individuals had

cancer, and their median age was 74. In

2006, after an extended legal battle be-

tween the federal government and Oregon,

the U.S. Supreme Court upheld the law

by a 6-to-3 vote. In March 2009, the

state of Washington passed a similar law,

and other states are currently considering

similar legislation. On the other hand, 35

states have laws explicitly criminalizing as-

sisted suicide (Hoffman, 2007).

Critics of the Oregon and Washington

laws and of the right-to-suicide movement

argue that the suicidal acts of patients

with severe or fatal illnesses may often

spring largely from psychological distress

(Foley & Hendin, 2002). Indeed, a num-

ber of studies suggest that half or more

of severely ill patients who are suicidal

may be clinically depressed (Werth,

2004; Chochinov & Schwartz, 2002).

Thus, in some cases, it may be more ben-

eficial to help individuals come to terms

with a fatal illness than to offer them a

license to end their lives. On the other

hand, according to yet other research,

decisions to seek physician-assisted sui-

cide are often made in the absence of

clinical depression (Rosenfeld, 2004).

Some clinicians also worry that the

right to suicide could be experienced more

as a "duty to die" than as the ultimate

freedom (Foley & Hendin, 2003; Brock,

2001). Elderly people might feel selfish in

expecting relatives to support and care for

them when suicide is a socially approved

alternative (Sherlock, 1983). Moreover, as

care for the terminally ill grows ever more

costly, might suicide be subtly encouraged

among the poor and disadvantaged?

Could assisted suicide become a form of

medical cost control (Brock, 2001)? In

the Netherlands, where physician-assisted

suicide and euthanasia were approved by

law in 2001 after years of informal accep-

tance, euthanasia is clearly on the increase

(Rurup et al., 2005). Around 2.6 percent

of all deaths in that country are now the

result of physician-assisted suicide and vol-

untary euthanasia (Hendin, 2002).

Suicide :1/ 249

•

The kir- ht tr- Commit Suicide

(ADAPTED FROM ORKIN, 1990; MALCOLM, 19901

n 1999 Dr. Kevorkian was convicted

of second-degree murder and sen-

tenced to prison for an assisted suicide

that he had conducted, filmed, and aired

on the television news show 60 Minutes. He was released From prison on parole

in 2007. However, his many court battles

have helped bring an important question to

the public's attention: Do individuals have

a right to commit suicide, or does society

have the right to stop them (Dickens et al.,

2008)?

The ancient Greeks valued physical and

mental well-being in life and dignity in death.

Therefore, individuals with a grave illness or

mental anguish were permitted to commit sui-

cide. Citizens could obtain official permission

from the Senate to take their own lives, and

judges were allowed to give them hemlock

(Humphry & Wickett, 1986).

Western traditions, in contrast, discour-

age suicide, on the basis of belief in the

"sanctity of life" (Dickens et al., 2008;

Eser, 1981). People in Western cultures

speak of "committing" suicide, as though

it were a criminal act (Sharma, 2009),

and allow the state to use force, including

involuntary commitment to a mental hos-

pital, to prevent it. But times and attitudes

are changing. Today the ideas of a "right

to suicide" and "rational suicide" are re-

ceiving more support from the public and

from many psychotherapists and physicians

(Curlin et al., 2008).

Public support for a right to suicide

seems strongest in connection with great

pain and terminal illness (Werth, 2004,

2000). Surveys show that more than two-

thirds of all Americans believe that termi-

nally ill persons should be free to take their

lives or to seek a physician's assistance to

do so (Harris Poll, 2005). In line with this

belief, the state of Oregon in 1997 passed

the "Death with Dignity" Act, allowing a

doctor to assist a suicide (by administering

a lethal dose of drugs) if two physicians

determine that the patient has less than six

months to live and is not basing the deci-

sion to die on depression or another men-

tal disorder. More than 400 people have

used this law to end their lives since 1997,

an average of 32 each year (Hoffman,

2007). Most of these individuals had

cancer, and their median age was 74. In

2006, after an extended legal battle be-

tween the federal government and Oregon,

the U.S. Supreme Court upheld the law

by a 6-to-3 vote. In March 2009, the

state of Washington passed a similar law,

and other states are currently considering

similar legislation. On the other hand, 35

states have laws explicitly criminalizing as-

sisted suicide (Hoffman, 2007).

Critics of the Oregon and Washington

laws and of the right-to-suicide movement

argue that the suicidal acts of patients

with severe or fatal illnesses may often

spring largely from psychological distress

(Foley & Hendin, 2002). Indeed, a num-

ber of studies suggest that half or more

of severely ill patients who are suicidal

may be clinically depressed (Werth,

2004; Chochinov & Schwartz, 2002).

Thus, in some cases, it may be more ben-

eficial to help individuals come to terms

with a fatal illness than to offer them a

license to end their lives. On the other

hand, according to yet other research,

decisions to seek physician-assisted sui-

cide are often made in the absence of

clinical depression (Rosenfeld, 2004).

Some clinicians also worry that the

right to suicide could be experienced more

as a "duty to die" than as the ultimate

freedom (Foley & Hendin, 2003; Brock,

2001). Elderly people might feel selfish in

expecting relatives to support and care for

them when suicide is a socially approved

alternative (Sherlock, 1983). Moreover, as

care for the terminally ill grows ever more

costly, might suicide be subtly encouraged

among the poor and disadvantaged?

Could assisted suicide become a form of

medical cost control (Brock, 2001)? In

the Netherlands, where physician-assisted

suicide and euthanasia were approved by

law in 2001 after years of informal accep-

tance, euthanasia is clearly on the increase

(Rurup et al., 2005). Around 2.6 percent

of all deaths in that country are now the

result of physician-assisted suicide and vol-

untary euthanasia (Hendin, 2002).

1!1:?1E.f.°1 !I) ..o ,:oh911..9 :

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• • •••

250 ://CHAPTER 8

is Suicide Linked io Age?

The likelihood of suicide varies with age. It is uncommon among children, although

it has been increasing in that group during the past several decades. Suicide by

adolescents is more common than suicide by children. Adolescent suicide has been linked to clinical depression, anger, impulsiveness, major stress, and adolescent

life itself. The high suicide attempt rate among adolescents and young adults may

be related to the growing number of young people in the general population, the

weakening of family ties, the increased availability of drugs among the young, and

the broad media coverage of suicide attempts by the young. The rate of suicide among Native Americans teens is twice as high as that among white American teens and three times as high as the African, Hispanic, and Asian American teen suicide rates.

In Western society the elderly are more likely to commit suicide than people in

any other age group. The loss of health, friends, control, and status may produce

feelings of hopelessness, loneliness, depression, or inevitability in this age group.

Treatment and Suicide Treatment of suicidal people falls into two major categories: treatment after suicide has been attempted and suicide prevention, While treatment may also be beneficial to relatives and friends, whose feelings of loss, guilt, and anger after a suicide fatality or attempt can be intense (Cerel et al., 2008), the discussion here is limited to the treatment afforded suicidal people themselves.

What Treatments Are Used after Suicide Attempts? After a suicide attempt, most victims need medical care. Some are left with severe in- juries, brain damage, or other medical problems. Once the physical damage is treated, psychotherapy or drug therapy may begin, on either an inpatient or outpatient basis.

Unfortunately, even after trying to kill themselves, many suicidal people fail to receive systematic follow-up care (Miret et al., 2009; Beautrais et al., 2000). In a ran- dom survey of several hundred teenagers, 9 percent were found to have made at least one suicide attempt, and of those only half had received later psychological treatment (Harkavy & Asnis, 1985). Similarly, in another study, one-third of adolescent attempters

reported that they had not received any help after trying to end their lives (Larsson & Ivarsson, 1998). In some cases, health care profession- als are at fault. In others, the person who has attempted suicide refuses follow-up therapy.

The goals of therapy are to keep people alive, help them achieve a nonsuicidal state of mind, and guide them to develop better ways of handling stress (Reinecke et al., 2007; Shneidman, 2001). Various therapies have been employed, including drug, psychodynamic, group, and family therapies (Tarrier et al., 2008; Baldessarini & Tondo, 2007). However, research indicates that cognitive and cognitive-behavioral therapies may be particularly helpful for suicidal individuals (Wenzel et al., 2009; Ghahramanlou-Holloway et al., 2008). These approaches focus to a large degree on the painful thoughts, negative attitudes, sense of hopelessness, dichotomous thinking, poor coping skills, and other cognitive and behavioral features that characterize the functioning of suicidal persons.