1. Learning about
Mood Disorders and
Suicide Risk
Suzanne Zinck, MD, FRCPC
IWK Health Centre
Dalhousie Department of Psychiatry

2. Objectives
• Understand the basic causes and treatment of
mood disorders
• Learn to recognize the signs of a mood disorder in
your students and how you can help.
• Learn about how mood disorders can affect
performance and some strategies to assist students
with their learning as they recover from a mood
disorder
• Learn basics of suicide risk assessment

3. MOOD DISORDERS

4. DSM-IV Mood Disorders
• Major Depression
• Dysthymia
• Adjustment disorder with depressed mood
• Bipolar I and II disorder
• Depression due to a general medical
condition
• Substance-induced mood disorder

5. Major Depressive Episode
• DSM-IV-TR (2000) criteria requires 5 out of 9
signs or symptoms for a two week period
– Sadness or Irritability
– Decreased Interest
– Increased Guilt and/or Low Self-Esteem
– Decreased Energy
– Poor Concentration
– Low or high appetite with possible weight change
– Psychomotor (movement)changes
– Poor or increased need for Sleep
– Self-harm/suicide

6. Mood or Mood Disorder?
• Mood changes are adaptive and assist us in
coping with change and stress
• If sustained low or irritable mood with
negative thinking that affects functioning
socially or in school or work for most of the
day every day for two weeks or more, then
it may well be a mood disorder.

7. SIGECAPSS
• SIG prescribe
• E energy
• CAPSS capsules

8. • Sleep
• Interest
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor changes
• Sad mood
• Suicide & self-harm

9. Mood Chart

10. Bipolar disorder
• 0.8% Bipolar I
• Up to 2% with inclusion of Bipolar II and 10% of whole spectrum
• Increased risk in children and adolescents with psychotic depression or
vegetative features (approximately 15-20%)
• Early (childhood) onset is controversial
– mixed states and rapid-cycling may predominate
– may not meet DSM-IV criteria: if not, what is it?
• Treatments:
– Medication:
• Lithium, valproate or combination
• Lamotrigine
• Atypical antipsychotics
• SSRI’s (?switch)
– Psychotherapy

11. Rates of depression in children
General population:
– Pre-schoolers 0.3-0.9%*
– School age 1.5-3% (boys > girls)
– Adolescence
• Early teens 1-6% (girls > boys)
• For all syndromes 10%
• Late teens (girls>boys)
Males 12%
Females 21-24%

12. Duration of depressive disorders
• Mean durations:
– Major depressive episode (MDE): 8-13 months
– Dysthymia: 3 years
– Adjustment disorder (<6 months by definition)
• 69% will have MDE within 5 years of diagnosis
with dysthymia
• 30-72% children with MDE will relapse within 5
years.
12

13. Double Trouble:
Comorbidity is common
• 50% depressed will have another mental disorder
• Anxiety disorders
– 34% (> in girls)
• Conduct disorder (law breaking)
– 40% (> in boys)
• Oppositional defiant disorder (rule-breaking)
• Eating disorders
• Substance use
• ADHD
‘Bad’ or ‘Sad’?

14. Etiology: Causes Aplenty
• Interaction likely among genetic risk (heredity),
in-born temperament, learned cognitive style,
learned behaviours and various forms of stress.
• Likely multiple contributors as no single
biological factor found in all subgroups of
depressed adults or youth
• Problems assessing causes versus consequences
• Which comes first? Detailed time course can tell.

17. Development affects
symptom presentation
of mood disorders.

18. Early school-age
6-8 years old: 9-12 years old:
– Lethargy As for 6-8, but also:
– Sleeping problems -Low self-esteem
– Irritability -Helplessness
– Separation anxiety -Guilt
– Prolonged unhappiness -Self-destructive behaviours
– Poor school performance -Suicidal ideation
– Accident-proneness -Aggression
– Phobias - even Psychotic features
– Attention-seeking behaviour

19. Adolescence (13-18 years old)
• As with children, plus:
• Concern about the future
• Pessimism
• Worthlessness
• Apathy, “bored”
• Vegetative signs and psychosis
• Self-harm:
– Lethal suicide attempts
– Substance use
– Eating disorders
– Antisocial behaviour

20. Signs of depressed mood in the
classroom
• Decreased grades
• Sad face/tearfulness
• Appears tired
• Appears overwhelmed
• Poor attendance or leaving early
• Cranky; giving attitude
• Late assignments
• Change in quality of work
• Social isolation: drops friends and activities
• Visible scars of self-harm

21. Downward spiral
Depression affects thinking, action and self-concept.
Problems at school can lead to decreased self-
esteem and conflict with parents. They can
withdraw from activities and see friends less or
lose friends. They can become targets of bullying
due to sad or reserved behaviour. They may not
know what is happening and become hopeless.
This may lead to suicidal thoughts and acts of self-
harm.

22. Risks of untreated depression
• Safety: self-harm or suicide
• Failing a grade
• Lose social supports
• Drug abuse
• Damage to family relationships

23. Self-harm and suicide
• Rare event in the population but not among
depressed youth.
• 50% of mood disordered youth have ideas/plans
• Up to 15% lifetime completion risk depending on
co-morbidity.
• Youth who talk about it still at risk
• Cutting/burning never simply a “gesture”
• Asking decreases risk not increases it.
• Call parent or GC right away if suspect suicidal.

25. I think she’s depressed.
What now?
• Ask student, confidentially, caring.
• Explain limits of confidentiality.
• Expect stigma and irritability: don’t give up.
• Speak to guidance counselor/Teen Health
• Let student know about next steps
• Call parent: check-in; provide referral info.
• Invite parent to school meeting if needed
• Consider & discuss adaptations in class
• Encourage activities with adaptations

27. Getting teens to further help
• Public & private options: depends on ability
to pay or insurance coverage:
IWK Central Referral (902) 464-4110
MHMCT (Mobile Crisis Team) (902) 429-8167
Local Mental Health clinics outside HRM
Parent can refer to private psychologist or social
worker.

28. Treatments
• Pharmacotherapy
– SSRIs
– SNRIs
– SARI ( trazodone ) for sleep
– Lithium carbonate and antipsychotics
• Psychotherapy
– IPT
– CBT
– Family therapy
• Combination therapy
• Lifestyle modification

29. Treatment
• Alone or in combination:
– Skills-based psychotherapy
– Medication (antidepressants)
– Parent and teen education
– Liaison with teachers, GC and VP of school
– School meetings
– Increase or resume positive activities
– Level of treatment by severity & risk

31. Assisting in the school
• Ensure confidentiality
• Longer time for assignments and projects
• Deferred or alternate exams
• Encouragement
• Matter-of-fact acceptance
• Classroom education independent of event
• Call parents as needed about attendance,
performance.
• Let therapist or psychiatrist know if permitted

35. SUICIDE RISK ASSESSMENT

37. Suicidal ideation
VERY COMMON
14% boys
24% girls
50% depressed teens will attempt in lifetime.
Suicide attempts peak during teen years, after which
there is a marked decline in frequency.
Completed suicides increase throughout teen years into
adulthood.
CDC, 2000 37

38. Suicide prevalence
Pre-pubertal children:
Very rare
Adolescents:
Age 5-14:
1.5 per 100,000 (boys)
0.6 per 100, 000 (girls)
Age 15-19:
8.2 per 100,000 (total)
Ages 19-25:
22.4 per 100, 000 (white males)
4.5 per 100, 000 (white females)

39. Impact of suicidality
In 2001:
•19% of high school students “seriously
considered attempting suicide”
•15% made a specific plan
•8.8% made an attempt
•2.6% made a medically serious attempt
Youth Risk Behavior
Survey (YRBS),

40. Assessment of suicidality
•
Often time-limited in ER & office
•
In office, a screen of risk and stratification using known
information about your patient and their family is required.
Screening assessment can determine whether an ER assessment
•
or admission is required or whether an office appointment can be
made.
•
Phone contact may be needed between visits.
•
Use MHMCT if available (902) 429-8167

41. Full crisis intervention includes a diagnostic
•
and a therapeutic interview
Assessment for depression, anxiety and
•
psychotic and substance abuse disorders
Once diagnoses and stressors understood, the
•
ER assessor and family doctor can collaborate
on a safety plan and protocol on use of office
versus ER.
This can treat not just manage patients with
recurrent self-harm.

42. Risk assessment has a time course
The psychiatric and gender-specific diagnostic profiles of youth
suicide attempters are quite similar to the profiles of those who
complete suicide.
Complex issue: multiple factors must be assessed to determine
risk
Acute on chronic risk is assessed because suicide risk is a
dynamic state.
ACUTE = now CHRONIC = baseline risk
Example 1: Past attempt increases chronic risk.
Current plan increases acute risk.
Example 2: SUD increases chronic risk.
Intoxication increases acute risk.

43. Interviewer’s goals
•
Obtain detailed information
•
Increase psychological awareness in patient and family of
situation including thoughts, feelings and events
•
Family involvement and reactions: what does support or lack
of look like in that family?
•
Assess teen’s developmental stage & decision-making style
•
Mental Status Examination: Observe affect and reactions of
patient & family closely! No change means that there may be
little to no change in risk even if teen agrees to outpatient
safety plan (“ contract”).
•
Make risk assessment and safety plan and disposition
decision

44. Exploring suicidal ideas and acts
•
Ideation frequency
•
Duration
•
Content
•
Preparation & access to lethal means
•
Rescue potential before, during, after attempts
•
Understanding of risk of attempts
•
Intent of attempt
•
Changes in motivation and intent
•
New stressors as a result of or during psychiatric illness
and the patient’s understanding of the meaning of these
events

45. Risk assessment in mental status
examination

Affect: closed, angry, tearful, anxious

Mood: congruent? Do they know?

Sensorium: Intoxication

Speech: coherent?

Thought content: stressors known? Are
problems seen as solvable?

Thought form: flexible? Rigid? Psychotic?

Reasoning ability: normal or compromised?

Psychomotor: agitated, apathetic and shut-
down?

46. Stressful Life Events
•Most common precipitants or interpersonal
conflict or loss
•Parent-child more common among younger
teens.
•Romantic conflict more common among older.
•Discord is a risk factor for attempted and
completed suicide, especially if it is unrelenting.
•Legal or disciplinary problems for those with
disruptive behaviour also a risk

47. Rating Risks
•Risk of suicide has both acute and chronic component
•Be vigilant of change in acute risk
•Examine history for new or worsening life events
•Focus on consequences & meaning of an event to youth
•Understanding meanings of events will allow points of intervention & also
accurate risk assessment
•Check on daily activities. Ask about “typical day” and “today”
•New self-harm behaviours even very “mild” and medically not serious
increase risk Worsening frequency or severity of self-harm behaviours in a
person who habitually self-harms is a sign of increased acute risk.
•You are never wasting any clinician or family members time by insisting on
an ER assessment for intervention and/or possible admission.

48. Decision-Making in the Office or
ER
•There is no suicide decision tree for all locales
•Risk is a balance of diathesis interacting with life events and
other risk factors
•Don’t contract if there is missing or vague information
•“Ifs” are not part of a workable solution, especially around an
issue over which the youth has no control.
•Youth must have a supportive environment to return to; family
work in ER may be needed, otherwise as inpatient.
•If in doubt, check own reaction and if info or support missing,
then refer to ER or admit.
•A first admission is always an intense ambivalent experience for
a youth & family. Admission can be a new crisis for family that
can lead to effective crisis intervention.

50. Resources
www.teenmentalhealth.org

TASR-A : Tool for assessment of suicide risk

Depression assessment guidelines

Parent, school and teen handouts on variety of
mental health topics

51. Questions?

52. For Own Study: Risk Factors Review
The following slides were not included
in the presentation talk due to time
considerations. They provide important
background that guides the
recommendations in the presentation
& are suggested for review on your own.

53. Psychiatric Diagnosis = Risk
90% suicide victims have diagnosis
9-fold increased risk if Axis I disorder present
80% community & referred cases of suicide
attempts have disorders
Chronicity and severity impose greater risk

54. Psychiatric diagnosis = Risk
Bipolar disorder:

Greatly increased risk of attempts (50 %) with
completion (10-25%).

Mixed states may be a risk factor for completed
suicide
Schizophrenia
15% lifetime risk of completed suicide

55. Age

Very rare among prepubertal youth globally

Increase at age 12 may be due to:

Increase in depression rates

Substance use

Complex social lives

Activation of stress-diathesis

56. Gender

Completed suicide is 5 times more common among males 15-
19 years old in NA, Western Europe, Australia and NZ.

Rates are equal between sexes in Singapore.

More women die by suicide than men in China

Substance use and lethal methods are more common in men

Ingestion is more common in women

(30% women vs. 6.7% men) but in China, ingestion is more
lethal so more women die there.
While among transgender or gay youth, there is higher
completed suicide rate in studies, this increased incidence of
suicide is accounted for by whether a psychiatric diagnosis is
present. Always screen and also ask about intimidation or
discrimination.

57. Ethnicity

Mixed results by community not ethnic
identification

Native Canadians are at highest risk overall

Caucasian Canadians have higher rates than
African Canadians but this gap is closing
especially among males (1986-1994).

58. Psychiatric Diagnosis = Risk

Depressive illness

49-64%

Increased OR of 11-27

More common among female completed
suicides

Substance abuse and conduct disorder are higher
risk comorbidities

Decreased judgment

Increased impulsivity

59. Cognitive & Personality Factors

Hopelessness or seeing problems as unsolvable

Poor interpersonal problem-solving

Social skills

Aggressive-impulsive behaviours

60. Suicide genes
•Family history of suicidal behaviour greatly increases
risk of completed suicide: heritability of 43%.
•Possible defect in serotonin transporter receptor and
5HT1A receptors in pre-frontal cortex and dorsal raphe
nucleus.
•Other correlates:
•Decreased CSF 5-H1AA
•Distinctive genetic haplotypes among suicide completers and
attempters compared to single-gene polymorphisms.

61. Family Functioning

Parental psychopathology

Effects of youth’s depression symptoms on
communication

High expressed emotion can worsen symptoms

Attachment not studied prospectively

Positive relationships and strong cohesion are
protective factors

62. Socioeconomic Status

No differences among completed suicides

Attempters are more likely to be poor

Youth with few social supports: not in school,
no job, few close friends are at higher risk.
Routines and positive social contact are
protective.

63. Child abuse

Past history of physical abuse confers risk
independently

Mediates risk in cases of interpersonal conflict,
social isolation or re-victimization via bullying.

Sexual abuse link is much less strong