Depression and Bipolar Disorder (aka Mood Disorders) A Primer By Lisa Sniderman, LCSW
Topic 1: Diagnosing Mood Disorders
Major Depression– DSM- IV (Psych Bible) Five or more of these symptoms during the same two-week period: 1. Depressed mood– feeling “sad” or “empty”1 most of the day, nearly every day 2. Markedly diminished interest or pleasure in most or all activities, nearly every day 3. Appetite changes (↑ or↓), weight changing more than 5% in a month 4. Insomnia or hypersomnia (oversleeping) nearly every day 5. Restlessness or lethargy nearly every day 6. Fatigue or low energy nearly every day 7. Feelings of worthlessness or excessive/inappropriate guilt2 nearly every day 8. Impaired concentration, decision-making3 nearly every day 9. Recurrent thoughts of death or suicide4, or a suicide plan or attempt5
Topic 1: Diagnosing Mood Disorders
Major Depression cont’d The symptoms cause clinically significant distress or impairment in functioning. The symptoms can’t be caused by meds/drugs/alcohol or a health problem If the symptoms occur after a major loss, then they are only considered to be an episode of Major Depression if they last more than 2 months OR they are severe (i.e., suicidal thoughts, extreme guilt, total inability to function)
Topic 1: Diagnosing Mood Disorders
Variations on Major Depressive Episode: Recurrent– 2 or more episodes (at least 60% of people have this)
With Seasonal Pattern – Most episodes start in winter, remit in spring With Postpartum Onset– DSM-IV says within 4 weeks, PPD experts say within a year Chronic– episode of 2 years or longer Melancholic, or “typical”– Can’t be “cheered up” by life events; ↓ appetite; depression worse in morning; waking up too early; excessive guilt Atypical (2-3x more common in women)–Can be temporarily “cheered up” by events; ↑ appetite; excessive sleep; leaden feeling in limbs; sensitivity to rejection by others. Severe With Psychotic Features–Hallucinations (seeing/hearing things); delusions (false beliefs firmly held– for ex., that one is being persecuted or controlled)
Facts about Depression According to the World Health Organization… •
Depression affects 121 million people worldwide
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Fewer than 25% of those with depression have access to treatment
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Among adults ages 15-44, depression is the 2nd greatest medical cause of DALY (Disability Adjusted Life Years) in the world. Will be 2nd greatest cause of DALY among all age groups by 2020.
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Depression can be diagnosed reliably by a family doctor
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80% of patients respond to medications and/or therapy
According to the DSM-IV… •
In some cultures, depression takes the form of somatic (bodily) complaints rather than sadness or guilt.
Facts About Depression, cont’d •
For example, depression may be experienced as “nerves” or headaches in Latino cultures; weakness or “imbalance” in Asian cultures; or problems with the “heart” in Middle Eastern cultures. These expressions are not a sign of “denial.”
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Children may experience depression as irritability, stomach/headache, withdrawal.
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Depression can only be diagnosed by talking to a patient.
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Lifetime risk for depression in women is 10-25%, for men 5-12%
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Major depression increases the risk of death in “young old age” (55+) fourfold and is correlated with chronic health problems like high BP, heart disease, diabetes.
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Other mental disorders frequently occur with depression. These include substance abuse/dependence; panic attacks; general anxiety6; OCD; eating disorders.
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Untreated, an episode of Major Depression typically lasts 4 months or more
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Up to 15% of people with severe depression complete suicide
Topic 1: Diagnosing Mood Disorders
Dysthymia– DSM-IV (“Depression Lite”– more long-lasting but less severe than Major Depression)
Depressed mood most of the day, most days of the year, for at least 2 years. Two or more symptoms while depressed: 1. Poor appetite or overeating 2. Insomnia or hypersomnia
3. Low energy 4. Low self-esteem (feeling uninteresting, inadequate, incapable) 5. Poor concentration or decision-making 6. Feelings of hopelessness Symptoms must cause clinically significant distress or problems in functioning and can’t be caused by meds/drugs/alcohol or a health problem.
Topic 1: Diagnosing Mood Disorders
Dysthymia cont’d Dysthymic Disorder usually starts before age 21. People with this disorder typically say, “I’ve always been this way.” This makes it different from Major Depression, which comes in episodes and is a marked change from a person’s usual state. Dysthymia is only diagnosed if the person’s symptoms have never been severe enough to be Major Depression, or if it has been at least 2 months since a Major Depressive Episode. Affects children of both genders equally, but in adulthood it is 2-3x more prevalent in women.
Topic 1: Diagnosing Mood Disorders
Dysthymia cont’d Up to 75% of those with Dysthymia will eventually develop Major Depressive Disorder. In fact, if Dysthymic Disorder precedes Major Depressive Disorder in a person’s history, the person is less likely to recover fully between episodes of Major Depression and is more likely to have more frequent episodes of Major Depression.
Most people who seek clinical attention for Dysthymic Disorder have “superimposed Major Depressive Disorder,” and that is what causes them to seek treatment. Treatment for Dysthymic Disorder is similar to treatment for Major Depressive Disorder. However, talk therapy is vital due to the chronic , unrelenting nature of the illness and the way it shapes a person’s thoughts and beliefs over time.
Topic 1: Diagnosing Mood Disorders
Bipolar Disorder I– DSM-IV Although most people with this disorder also have episodes of Major Depression… The defining feature of Bipolar I is actually one or more Manic or Mixed episodes. Manic Episode = Abnormally high or irritable mood for at least 1 week. Must have at least 3 of these symptoms (4 if mood is irritable only):
1. Inflated self-esteem, grandiosity 7 2. Decreased need for sleep—i.e., 3 hours a night 3. More talkative, pressured speech 4. Flight of ideas, racing thoughts
5. Distractibility 6. Increase in goal-directed activity8 (i.e., sexual conquests, ambitious work projects) 7. Risky activities9 (spending sprees, promiscuity, foolish investments)
Topic 1: Diagnosing Mood Disorders
Bipolar Disorder I, cont’d Mixed Episode = For at least 1 week, symptoms that meet criteria for both a Manic Episode and a Major Depressive Episode. Think “hell in fast-forward.” Typical Mixed Episode: 1. Rapidly shifting moods (sadness, euphoria, irritability) 2. Agitation, insomnia 3. Psychotic symptoms (hallucinations, delusions) 4. Suicidal thinking To diagnose both Manic and Mixed Episodes, symptoms must cause clinically significant distress or problems in functioning and they can’t be caused by meds/drugs/alcohol or a health problem.
Topic 1: Diagnosing Mood Disorders
Bipolar Disorder II– DSM-IV (“Bipolar Lite”– same deep lows, but lower highs, than Bipolar I) The defining feature is one or more episodes of Major Depression alternating with at least one Hypomanic Episode: Persistently high or irritable mood for at least 4 days, including at least 3 of the symptoms for a Manic Episode. BUT… here’s the difference. The episode is not severe enough to cause impairment in functioning, or to require hospitalization, and there are no psychotic symptoms. The episodes of Major Depression in Bipolar II are just as serious as in Bipolar I. Suicide rate is the same for both disorders.
Topic 1: Diagnosing Mood Disorders
Cyclothymia– DSM-IV The defining feature is a chronic mood disorder lasting at least 2 years, and involving many periods of dysthymic symptoms alternating with hypomanic symptoms (not necessarily a full Hypomanic Episode). As with diagnosing all Mood Disorders, symptoms of Cyclothymia must cause clinically significant distress or problems in functioning. (i.e., person seen as “unreliable.”) As with Dysthymia, this is a chronic rather than an episodic illness, and it typically starts before age 21. There is a 15% to 50% risk that someone with Cyclothymia will go on to develop Bipolar I or II.
What is “Bipolar Depression”? 1. An episode of Major Depression that occurs as part of an existing Bipolar Disorder. The distinction is made because in this case, the episode likely will respond better to a mood stabilizer than to an antidepressant alone. Antidepressants alone may bring on hypomanic/manic symptoms.
2. An episode of Major Depression that shows signs of possibly being part of an undiagnosed Bipolar Disorder, OR of possibly being on the “bipolar spectrum” (somewhere between Major Depression and Bipolar Disorder). The distinction is made because if the person’s depression has the signs listed below, they may benefit
more from a mood stabilizer than from an antidepressant. •
Four or more repeated episodes of major depression
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Young age (early 20s or younger) at first episode of major depression.
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A first-degree relative has bipolar disorder
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When depressed, symptoms are "atypical” OR
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When depressed, insomnia is severe (only 2-3 hours sleep on average)
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Episodes of major depression last three months or less
“Bipolar Depression” cont’d •
Psychotic symptoms accompany the depression
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The person has had severe postpartum depression
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Experiencing hypomania or mania (not just insomnia or irritability) while taking an antidepressant
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The person has “burned out” on an antidepressant– it stopped working within a few months
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Three or more antidepressants have been tried, and none worked.
These signs do not mean the person has an underlying Bipolar Disorder. They simply predict which treatments are likely to work best. It is possible for someone to have “pure” Major Depression, with no leanings toward bipolarity, and still require a mood stabilizer to control the depression. [For this and the previous slide, I used the following resource: http://www.psycheducation.org/depression/02_diagnosis.html. GREAT site. Includes diagram of the Bipolar Spectrum and info on tools that psychiatrists use to more accurately diagnose mood disorders.]
Lisa’s Pet Spiel: We’re learning more about Mood Disorders all the time– but they are complex, and much remains a mystery. The DSM-IV diagnoses and the concept of a “bipolar spectrum” are just the most educated guesses we have as to the physiology of Mood Disorders. It could all prove wrong someday!
Facts About Bipolar Disorder According to the DSM-IV… •
Bipolar Disorder can only be diagnosed by interviewing the person.
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Manic/mixed/hypomanic episodes come on suddenly, over the course of 1-2 days at most10. Depressive episodes come on more gradually and last longer.
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60-70% of manic/mixed/hypomanic episodes occur right before or after a depressive episode.
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On average, people with Bipolar Disorder have 4 mood episodes in 10 years.11
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Most people regain most of their functioning between episodes, but 20-30% struggle continuously with mood symptoms.
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In every culture, 1-2% of people meet criteria for Bipolar I, and .5% meet criteria for Bipolar II. But not all cultures call it “bipolar disorder,” or consider it an illness.
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Affects males and females equally. Average age at onset = 20.
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A first manic episode after 40 is rare, and may indicate a physical health problem.
Facts About Bipolar Disorder, cont’d •
10-15% of people with Bipolar I or II complete suicide.
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10-20% of people with Bipolar I or II experience “rapid cycling”– 4 or more mood episodes (depressed, manic, or both) in 12 months.
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If cycle is more rapid than this, diagnosis is “Bipolar Not Otherwise Specified.” But note: very rapid cycling is rare in adults.
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Women with Bipolar I or II have markedly increased risk for severe postpartum depression12 and postpartum psychosis. This is a rare (1-2 per 1,000 births) but serious complication of childbirth that requires hospitalization so the mother doesn’t harm herself or her baby.
Children (Ages 6-17) and Bipolar Disorder– information from NAMI
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Was once thought rare, but now 7% of kids seen at psychiatric facilities have bipolar disorder
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Mood cycling in kids tends to be VERY rapid, several cycles a day13
Facts About Bipolar Disorder, cont’d •
In kids, it’s important to distinguish bipolar disorder from ADHD. While both involve hyperactivity and distractibility, only bipolar disorder involves these symptoms:
Elation– “Disneyland” or “Jim Carrey” all the time Hypersexuality (even in young kids) Flight of ideas– constantly jumping from topic to topic Grandiose behavior– jumping out windows, attempting to teach the class Decreased need for sleep (for kids, 4-6 hours counts as decreased need) In kids, the illness tends to be more severe and have fewer periods of remission than in adults. Impulsivity of adolescence increases suicide risk. Treatment with medication is more complicated due to lower body weights, unpredictable effects, potential for serious long-term side effects.
Topic 2: Causes & Treatments Current wisdom says mood disorders are caused by two interrelated factors, which play out differently for every person: • •
Genetic predisposition Life circumstances, illness, stress
This is known as the “Bio-Psycho-Social” or “Diathesis-Stress” model. (Diathesis = tendency or predisposition)14
For most people, it’s not “nature OR nurture”… it’s both!
Diagram of Diathesis-Stress Model (thanks Wikipedia)
Topic 2: Causes & Treatments
So where does brain chemistry fit in? Brain chemistry interacts with both parts of the equation: stress AND vulnerability. HOW EXTERNAL FACTORS (STRESS) + BRAIN CHEMISTRY INTERACT: •
Trauma, abuse, poverty, illness, poor nutrition– all affect brain chemistry in ways that can affect mood and functioning. Some effects are long-lasting (as in trauma and abuse), some are more fleeting (as in fever or transitory stress).
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Abruptly stopping medication, taking the wrong dose, or taking the wrong medication, can cause a relapse of symptoms.
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Talk therapy & social support also affect brain chemistry, and may do so in a more enduring way than medication.
Topic 2: Causes & Treatments HOW INHERITED VULNERABILITY + BRAIN CHEMISTRY INTERACT:
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Trauma, abuse, emotional deprivation, prolonged stress, etc. may either create a vulnerability to a Mood Disorder, or may make an existing vulnerability worse.
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Children of chronically depressed parents are at higher risk for depression themselves, whereas children of parents who have depression but who get treatment have a relatively lower risk. This suggests that the home environment can either exacerbate, or compensate for, any inherited vulnerability.
One thing is clear: brain chemistry, daily events, and vulnerability are in constant interaction. Each affects the others. This is why the best treatment is integrated: it addresses both stress AND vulnerability.
Topic 2: Causes & Treatments Treatments that address the “biological” or “vulnerability” side: • • • •
Medications, other medical treatments (vagus nerve stimulation, ECT) Nutrition Exercise Treatment of physical illnesses
Treatments that address the “environmental” or “stress” side: • •
• • •
Therapy Case management (practical help with financial, legal, occupational, social, educational problems) Meditation Spiritual counseling Support groups, addiction recovery groups
Most common treatments for Mood Disorders 1) Medications. These tend to be the first approach for acute manic/mixed states in Bipolar I. These states involve loss of contact with reality and risky behavior (and, often, hospitalization). Immediate stabilization is crucial. Meds are also often the first approach when depressive symptoms are severe enough to require hospitalization, or when the depressed person seeks the help of a physician or a psychiatrist first, rather than a therapist. Most people (65%-80%) do respond to medication, but particularly with antidepressants, there is usually some trial-and-error 15. About 20%-35% of people do not respond significantly to any medication. In severe depression, risk of suicide is heightened during the first 2-3 weeks on meds. The person still has suicidal thoughts, but now has more energy to act on them.
Categories and Types of Medication Antidepressants
Most commonly prescribed: SSRIs. Paxil, Prozac, Zoloft, Celexa, Lexapro, Luvox. Side effects can include nausea, jitters, sleep problems, withdrawal syndromes.
SNRIs. Cymbalta, Pristiq, Effexor. Generally more stimulating than SSRIs (insomnia, jitters). Cymbalta is also used to treat fibromyalgia + chronic pain.
Tricyclics. Older class of drugs, more sedating, good for insomnia & bipolar depression. Tend to be used when SSRI/SNRIs fail, because of stronger side effects. These include dry mouth, weight gain, constipation, cardiac damage.
MAOIs. Older class of drugs, used “when all else fails” due to severe drug/food interactions (aged cheese, smoked meats). But they are miracle drugs for some.
Categories and Types of Medication Mood Stabilizers
Used to treat manic symptoms; to treat bipolar depression; and to increase the effectiveness of antidepressants for people with severe depression. ďƒ˜ Lithium carbonate. In use since the 1950s. Highly effective for many people. Concerns with use include tremors, diarrhea/vomiting, weight gain16, potential for kidney damage, and potential for lithium toxicity, which can occur suddenly. ďƒ˜ Depakote. Also an anti-seizure med. Generally fewer side effects than lithium, but many people experience weight gain. Potential for seizures if stopped suddenly. ďƒ˜ Lamictal. Also an anti-seizure med. Used solely to prolong the period between mood episodes. Other meds needed to control active mania or depression. Milder side effects. Dizziness, headache, upset stomach.
Categories and Types of Medication Antipsychotics Used to treat hallucinations (false sensory perceptions that seem real)17 and delusions (false, fixed beliefs)18 in severe Major Depression, and in Bipolar Disorder I. Abilify & Seroquel can also be used to boost the efficacy of antidepressants.
Antipsychotics have the most severe side-effect profile of any class of medications, except chemotherapy. First-Generation Antipsychotics. Thorazine, Stelazine, Haldol, Prolixin, Mellaril. Now used mostly for emergency stabilization in hospitals19. Major concern is Extrapyramidal Symptoms (EPS) that can be permanent: tremors, involuntary movements, stiff gait. (Think of John Nash’s shuffling walk in “A Beautiful Mind.”)
Categories and Types of Medication Second-Generation Antipsychotics. Zyprexa, Risperdal, Seroquel, Geodon, Clozaril. Major concern is Metabolic Syndrome: significant weight gain, high triglycerides and “bad” cholesterol, increased risk of stroke, sudden cardiac death, blood clots, and diabetes. EPS are still a concern with these meds, too. Clozaril is generally the “last resort” because of 1% risk of agranulocytosis, a fatal blood disease.
Third-Generation Antipsychotics. Abilify. Metabolic Syndrome is less of a concern with Abilify, but serious side effects can still occur. Most common side effects are restlessness, insomnia, stomach upset. People who have severe manic episodes are the most likely to be on an antipsychotic medication longer-term. This is particularly true if they cycle more rapidly, or have symptoms even when they are between episodes.
Most common treatments for Mood Disorders 2) Therapy. This is often the first approach when a person seeks the help of a therapist. (Thanks, Captain Obvious!) Therapy is often as effective as meds, or more so, for dysthymia and milder depression. But if a person comes to a therapist with active suicidal thoughts or psychotic symptoms or a full-blown manic episode, the therapist likely will refer the person to the ER or to a psychiatrist. Therapy is less effective in these situations. (But it can be very helpful once someone’s symptoms are stabilized.) What types of therapy work best for Mood Disorders? For dysthymia/depression: Cognitive-behavioral therapy (CBT) is the darling of researchers and health insurance companies alike because it is short-term and highly effective. (It’s my darling, too. Mwah!)
Most common treatments for Mood Disorders THOUGHTS affect FEELINGS + BEHAVIOR. Cognitive-behavioral therapy focuses on the way in which a person’s thoughts (cognitions) affect their feelings and their behavior. Therapists help people identify their “cognitive distortions”– ways of viewing themselves and the world that perpetuate depression. (Ranjana: “I am a horrible person.”) Therapists then help people come up with more realistic, adaptive ways of thinking. (Ranjana: “I’m not so bad.” She has concrete evidence of this in her life.) BEHAVIOR affects THOUGHTS + FEELINGS. The “behavioral” part comes in when therapists help patients identify behaviors that fuel negative thoughts and feelings. (Julie: shoulders her roommate’s problems, at her own expense.) Therapists then encourage people to gradually replace these behaviors with more adaptive ones. (Julie: could set self-protective boundaries.) Note: CBT does not try to directly change people’s FEELINGS. That is impossible.
Most common treatments for Mood Disorders Other types of therapy used to treat Mood Disorders •
Psychoeducation—teaching people how to manage symptoms, use meds, and cope with stress. This is useful for people who have trouble preventing relapses.
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Psychodynamic/psychoanalytic (“Freudian”)—using a longer-term approach that focuses on the past, particularly childhood, as a way to understand a person’s motivations, conflicts, and hidden desires.
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Family/group therapy– helping families become more supportive of members with mood disorders, and resolve conflicts; helping those with mood disorders learn from the experiences of others and gain support.
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Substance abuse treatment—for people with co-occurring substance abuse and a Mood Disorder, both disorders must be treated in order to ensure long-term recovery and reduce suicide risk. Integrated treatment is best.
Other treatments ECT (“shock treatments”). Can be instantly effective for severe, unremitting, treatment-resistant depression and mania. (April: “instant antidepressant.”) Also useful in situations where people can’t tolerate medication or don’t want it (pregnancy, nursing, spiritual beliefs, etc). Much safer than in the past. Side effects include temporary memory loss, confusion, nausea, aches. Vagus nerve stimulation. FDA-approved in 2005 for treatment of depression. Stimulating device is either implanted into the chest and neck, or externally placed in the ear. Some people report dramatic results, but overall, the verdict is still out. Meditation, spiritual practices. Many people with Mood Disorders find that spiritual practices are a great help in maintaining a sense of balance. Caveat: people may blame themselves when these practices alone fail to control their symptoms20, and others may fuel the fire by accusing them of inadequate “enlightenment,” of being “possessed,” or of “lacking faith.”
Other treatments, cont’d Nutrition. Some people with Mood Disorders find that dietary changes, such as eliminating processed foods, or adding Omega-3 oils, lead to better symptom control. Proper nutrition can also control some of the weight gain and metabolic problems associated with certain meds. Exercise. In dysthymia and mild depression, regular exercise can be as effective as medication. It is a good idea for everyone, of course! Medical treatment of co-occurring health problems. Chronic infections, diabetes, high blood pressure, sleep disorders, and other health problems both impact mood symptoms and are impacted by them.
Case management. While not technically a “treatment,” case management services can be vital for people with Mood Disorders who are poor, homeless, unemployed, uninsured, and/or who cannot advocate for themselves.
Topic 3: The “recovery model” •
Began in the mid-1990s. Key leaders include Pat Deegan, Ph.D., (Google “Deegan Conspiracy of Hope” for a very stirring essay) and Fred Frese, Ph.D., as well as many other mental-health consumers and advocates. The movement arose from concern about overly medical approaches to treatment that stigmatize and isolate people; reduce self-determination; and make people passive recipients of care.
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Key concepts in the recovery model:
The individual defines “recovery” and sets personally meaningful goals. Ambivalence about using medications and other treatments is normal. Quality of life, and a sense of purpose, matter as much as symptom relief.
Even when incapacitated, people should be able to decide what treatments they want. (“Psychiatric advance directives”—legal in 12 states, including IL). People do not “lack motivation”– they adapt to survive in hopeless situations. Motivation is not inherent; it is created by the environment.
Topic 3: The “recovery model” This model is now the accepted standard of practice in mental healthcare. This does not mean all practitioners agree with it, or follow it. But policies have changed. For example, it is harder than it once was to hospitalize someone involuntarily. SAMHSA (Substance Abuse/Mental Health Service Admin., www.samhsa.gov) promotes the use of “evidence-based practices” that are based on recovery principles. Examples include: • • • • • •
Supportive Housing (safe, affordable housing with supports in place to maintain it) Integrated Treatment for Co-Occurring Disorders (no “zero tolerance” policies) Supported Employment (anyone who wants to work, can) Assertive Community Treatment (for people prone to hospitalization) Family Psychoeducation (teaching facts about the illness, and how to cope) Wellness Management and Recovery (a personal-goal-based intervention)
“Recovery” Does Not Mean “Neglect”
In pursuing personal goals, people often find that their symptoms get in the way. Thus, it’s helpful to link treatment goals to personal goals, rather than making treatment an end in itself. In many cases, untreated symptoms cause unwanted consequences. The person may need help connecting their symptoms with the consequences, but the insight must ultimately be their own. (Example: use of a “decisional matrix”, next slide) It is unethical to “let” someone repeatedly get hospitalized, arrested, or victimized as a way of forcing “natural consequences” upon them. Likewise, when there is a risk of suicide or personal harm, intervention is required. Once the urgent situation has passed, recovery-based care helps people build skills to minimize future crises and build greater self-determination.
Recovery in Process: My Decisional Matrix 1) PROS of taking meds Controls depression almost 100% Enables me to be a good parent Helps me progress in therapy Enables me to sleep after working nights
2) CONS of taking meds Causes constipation, dry mouth Can’t breast-feed Have to stay on top of refills Worries about heart problems due to high dose (none presently)
3) PROS of NOT taking meds
4) CONS of NOT taking meds
No worries about long-term effects Save $30 a month Feel independent and liberated
Depression and insomnia return Can’t take care of the kids or work Severe conflicts with spouse Depression affecting the kids
Topic 4: Suicide Risk & Prevention [Info for this topic taken from American Foundation for Suicide Prevention, www.afsp.org, and from my experiences working in emergency medicine]
Facts & Figures •
The rate of suicide has been increasing since 2000. In the U.S., nearly 1,000,000 people make an attempt each year.
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Women are 3 times more likely to attempt suicide than men, but men are 4 times more likely to complete suicide.
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90% of people who complete suicide have a diagnosable mental disorder.
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Risk is highest between ages 40 and 59, with 19 suicides per 100,000 people.
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Risk is almost nil between ages 5 and 14, but rises dramatically after age 14.
Topic 4: Suicide Risk & Prevention Risk Factors for Suicide • • • • •
Mood Disorders and other mental illnesses Alcohol abuse (particularly when combined with a Mood Disorder) Past history of attempts (25-50% of those who complete suicide had 1 or more prior attempts) Impulsivity Family history of depression and/or suicide Suicide Crisis– Immediate Risk
• • •
Significant losses, disappointments, failures (“precipitating event”) Depression intensified by strong emotions such as anguish, desperation, rage, anxiety, guilt, hopelessness, sense of total abandonment. Also, severe insomnia. Speech suggesting suicide in the near future. May be indirect, i.e., “It would be easier for my family if I weren’t around.” Themes of saying goodbye or going away.
Topic 4: Suicide Risk & Prevention Suicide Crisis—Immediate Risk
• • • •
Talking about death or suicide directly; describing a plan for suicide Unexpected actions –buying a weapon, acquiring a stock of medication, putting affairs in order Access to weapons or poisons while severely depressed Downward spiral of functioning– trouble at work or socially, increased use of substances, self-destructive behavior, loss of control, rage.
50% to 75% of people who complete suicide give some form of warning to a friend or family member beforehand. Early detection of depression (for example, noticing a loss of interest or pleasure in daily activities, or social withdrawal) is the best form of suicide prevention.
Topic 4: Suicide Risk & Prevention “So what do I do?” •
Tell the person you are concerned, and give examples from what they’ve said.
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Come out and ask the person if they are considering suicide, and whether there is a plan or method. Consider an open-ended question like, “What are your thoughts about suicide right now?” instead of a yes/no question.
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Tell the person you care, that they are not alone, that suicidal feelings are temporary and that depression can be treated.
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Do not try to talk the person out of suicide.
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Inform a professional immediately– or, call 911. Safety trumps confidentiality.
Topic 5: Skills for Listening and Support Listening is a fine art that even professional listeners (therapists) fail at constantly! When someone is struggling or in crisis, we want to help, but often we forget to listen.
What is Effective Listening? • • •
Communicating warmth and empathy Providing a non-judgmental, open space Being OK with silences
What Is Not Effective Listening? • • • •
“Trying to help”/giving advice/playing the expert Interpreting the person’s statements Jumping to conclusions Worrying about whether you’re an effective listener
Topic 5: Skills for Listening and Support [Info for this topic taken from: Miller, W. & Rollnick, S. (2002). Motivational Interviewing. 2nd Ed. Guilford Press, NY, NY.]
Motivational Interviewing– A style of communication used to help people build their own motivation, confidence, and readiness for change. According to the principles of Motivational Interviewing, there are four basic skills for listening to someone you’ve just met.
O. A. R. S. 1) 2) 3) 4)
Open-ended questions Affirmation Reflection Summary
Topic 5: Skills for Listening and Support Open-ended questions. Let the person tell the story by asking questions that invite a longer response. Avoid yes/no questions, factual questions, and forcing the person to pick from a list. If it can be answered in 1-3 words, it’s not open-ended. Examples: 1. “Do you think you might have depression?” (yes/no) 2. “Would you say you’re very worried, somewhat worried, or not worried?” (list) 3. “What school do you go to? What medication do you take?” (factual questions) BETTER: 1. “What concerns you about your friend’s behavior?” (open-ended) 2. “Tell me more about that experience.” (open-ended) 3. “What about that performance affected you the most?” (open-ended)
Topic 5: Skills for Listening and Support Open-ended questions, cont’d. When in doubt about how to phrase an open-ended question… “Tell me more about that” or “What concerns you about that?” are always safe. Use the person’s own exact language. (“Tell me more about feeling crappy.”) Avoid putting words in the person’s mouth. Example: Audience member– I think I might have a problem. I can’t sleep or eat, and I feel sad. ETD person—
Tell me more about your depression. (No!)
ETD person–
Tell me more about that./What concerns you about that? (Yes!)
Topic 5: Skills for Listening and Support Affirmation. Statements of appreciation and understanding. Noticing a person’s strengths & efforts. Examples: 1. 2. 3. 4.
“You’ve shown a lot of strength to deal with this alone for so long.” “It must be very hard to talk about all this. I appreciate that.” “You didn’t give up, even when it seemed no one believed you.” “If I were in that position, I’d be scared to confront my friend, too.”
Read the person’s signals; don’t overdo affirmation. It can be embarrassing to some. Affirmation should not veer into interpretation. Don’t get ahead of the person. If someone talks to you about their feelings, affirm them for talking about their feelings, not for “taking the first step in getting help” or “admitting to depression.”
Topic 5: Skills for Listening and Support
Reflection. Letting the person know you’re listening, and are attuned to their tone + content. Simplest method is to mirror what the person is saying, using their own language. Example: Audience member– Last night, my friend mentioned she was Googling ways to kill yourself. She was laughing in this weird way. I got completely freaked out. ETD person– It freaked you out that she had gotten to the point of Googling about killing herself. Audience member—Yeah, like she must really be depressed. What if she tries something and no one is there to stop her? ETD person– You’re worried that she is so depressed that she might actually try suicide, and not call anyone first.
Topic 5: Skills for Listening and Support Reflection, cont’d. It is simplest to keep reflection at the level of literal mirroring. However, sometimes the conversation feels “stuck.” For example, you have a feeling someone wants to come out and say that they’re depressed. You don’t want to put words in their mouth, but you do want to encourage the person to open up.
In this case, it is always best to “be British” and UNDERSTATE: Audience member– I haven’t felt like myself for months now. I’m really scared that nothing is working. ETD person– You think you might actually be a little depressed. The audience member now has a safe opening, either to agree (and state matters more strongly), or to disagree. Either way, you’ve avoided offending them.
Topic 5: Skills for Listening and Support Summary. Used at the end of a conversation, or periodically during a long conversation. Summary is a round-up of the ideas and themes that the person has presented to you. It’s useful in checking your own understanding of the situation, and it can help the person feel “contained,” as if the problem does have a beginning and an end. It can also help the person notice discrepancies in what they’ve said. Always invite the person to add their input and corrections. Example: “So, Angela, you have a number of concerns today. One is that your friend may be planning a suicide, or at least thinking about it. Another is that you don’t think the school social worker could be helpful. At the same time, you don’t feel like you can handle it on your own. Did I get that right? What would you like to add?”
Topic 5: Skills for Listening and Support Bringing It All Together: O.A.R.S. When do I use each skill? Open-ended questions keep the person talking. Affirmation is helpful when someone shares something very difficult. Reflection is helpful to remind the person you are listening and paying attention. Summary can be used at the end of the discussion, or as a “paragraph break” during long discussions. Does this mean I should say something every time the person says something? No. The other person should be doing most of the talking. Use O.A.R.S. skills when needed or helpful, but mostly just listen. What if I do get ahead of the person, and say something that angers them? Apologize. You could say, “I’m sorry, I got a little ahead of you there. That’s not what you meant. Let’s go back to what you said before; tell me more about that.”
Thank You Very Much! Resources Diagnostic Manual for Mental Disorders: DSM-IV-TR (2000). American Psychiatric Association, Washington, DC. Motivational Interviewing Manual: Miller, W. & Rollnick, S. (2002). Motivational Interviewing. 2nd Ed. Guilford Press, NY, NY. www.nami.org American Foundation for Suicide Prevention: www.afsp.org (includes toolkits for schools in the aftermath of a student suicide) Information on psychotropic medications: http://druginfo.nlm.nih.gov/drugportal/drugportal.jsp Information on the recovery model: http://blog.samhsa.gov/2011/05/20/recoverydefined-a-unified-working-definition-and-set-of-principles/