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• Mood disorders

Dr.Saman Anwar Faraj

M.B.Ch.B, F.I.B.M.S(PSYCHIATRY)

2. Mood Disorder

Mood change is the main psycho pathological feature.

The abnormality is more intense and persistent than normal variation in mood and often lead to problems in occupational and social functioning.

3. Mood disorder

mood disorderis the term given for a group of diagnoses in theDSM IV TR disordersin ICD 10.

English psychiatristHenry Maudsleyproposed an overarching category ofaffective disorder . The term was then replaced bymood disorder , as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.

Two groups of mood disorders are broadly recognized; the division is based on whether the person has ever had amanicorhypomanicepisode. Thus, there are depressive disorders, of which the best known and most researched ismajor depressive disordercommonly called clinical depression or major depression, andbipolar disorder , formerly known as "manic depressive" and described by intermittent periods of manic anddepressedepisodes.

4. Classification of mood disorders

DSM-IV-TR describes the followingepisodes :

1-Major Depressive Episode: lasts for 2 weeks

2-Manic Episode:one week

3-Hypomanic Episode: four days

4-Mixed Episode: one week

5. Classification of Mood Disorders contd

Major Depressive Disorder

Bipolar I Disorder= having a clinical course of one or more manic episodes and, sometimes, major depressive episodes.

Bipolar II Disorder: episodes of major depression and hypomania

Dysthymic Disorder : 2years

Cyclothymiacs Disorder

6.

Epidemiology of mood disorders;

19.3% of the general population develops a mood disorder (14.7% men, 23.9% women)

21.3% of women & 12.7%of men develop major depression.

Average age of onset for bipolar illness is mid to late twenties.

Average age of onset of depression is mid thirties.

Bipolar disorder occurs more in high socioeconomic groups.

Mania and depression are manifested by symptoms involving the effective, cognitive,Physical, social, and spiritual aspects of the individual.

7. Major depressive disorder

Common disorder, with a lifetime prevalence of about 15% ,perhaps as high as 25% in women.

The incidence of major depressive disorder is also high in primary care patients,in whom it approaches 10%, and in medical inpatients , in whom it approaches 15%.

An almost universal observation , is the two-fold greater prevalence of the disorder in women than in men.

The reasons for this difference have been hypothesized to involve hormonal differences, the effect of childbirth, and differing psychosocial stresses for women and for men.

8. Major depressive disorder

The mean age of onset is about 40 years ; 50% of all patients have an onset between age of 20-50 .

Although uncommonly, MDD can also begin in childhood or in old age.

Some recent studies suggest that the incidence of MDD may be increasing among people less than 20 years old.

MDD occurs most often in people without close interpersonalrelationships or in those who are divorced or separated .

No correlation have been found between socio-economic status and MDD

9. Etiology

Although the etiology of MDD is ambiguous and complex, it can be divided into three main groups: biological ,genetic ,and psychosocial.

Biological factors:

a. Biogenic amines :norepinephrine , and serotonin are the most implicated.

b. Other neuro-chemical factors: GABA ,and neuroactive peptides particularly vasopressin, and the endogenous opiates.

c. Neuro-endocrine regulation :adrenal , thyroid and growth hormone.

d. brain imaging abnormalities: still inconclusive.

Genetic factors :

genetic data strongly indicate that significant genetic factor is involved in the development of mood disorders. First degree relatives of MDD are 1.5-2.5 times more likely to have bipolar I disorder, and 2-3 times to have MDD. The concordance rate for MZ twins is about 50% while in DZ twins is 10-25%.

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3. Psychosocial factors :

a- life events and environmental stress:

The life event most often associated with a person later development of depression is losing a parent before the age of 11. The environmental stressor most often associated with the onset of an episode is the loss of a spouse.

b- Family.

c- premorbid personality factors.

d- learned helplessness.

e- cognitive theory.

11. Signs and symptoms

Two hallmarks of depression symptoms key to establishing a diagnosis are:

Loss of interest in normal daily activities You lose interest in or pleasure from activities that you used to enjoy.

Depressed mood. You feel sad, helpless or hopeless, and may have crying spells.

12. Signs and Symptoms Contd

3. Sleep disturbances

Insomnia or Sleeping too muchWaking in the middle of the night or early in the morning and not being able to get back to sleep.

4. Impaired thinking or concentration

Trouble concentrating or making decisions.

Problems with memory.( difficulty with short term memory).

13. Signs and Symptoms Contd

5. Changes in weight

An increased or reduced

6. Fatigue or slowing of body movements.

lack of energy.

Feel as tired in the morning.

Have trouble getting out of bed.

Feel like you're doing everything in slow motion, or you may speak in a slow, monotonous tone.

14. Signs and Symptoms Contd

7.Low self-esteem

Feel worthless.

Excessive guilt.

Pessimism, poor self-esteem.

Self-criticism8. Agitation

You may seem restless, agitated, irritable and easily annoyed.

Difficulty controlling your temper.

15. Signs and Symptoms Contd

9 . Physical complaints, such as gastrointestinal problems (indigestion, constipation or diarrhea), headache and backache. Many people with depression also have symptoms of anxiety.

Children, teens may react differently to depression.

Kids may pretend to be sick, worry that a parent is going to die, perform poorly in school, refuse to go to school, or exhibit behavioral problems.

16. Signs and Symptoms Contd

10. Less interest in sex.

11. Thoughts of death.

A persistent negative view of yourself, your situation and the future.thoughts of death, dying or suicide.

17. Differential diagnosis

1. Medical disorders:

Endocrine disorders, infections, metabolic disorders , nutritional deficiencies, connective tissue diseases , drugs (steroids , contraceptive pills, analgesics,..),etc.

2.Neurological disorders:brain tumors, infections, head injury , epilepsy ,etc.

3.Mental disorders:anxiety disorders, bipolar disorder, schizoaffective disorder, schizophrenia, substance abuse,Dementias and pseudodementia

4 .Uncomplicated bereavement.

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Depressive disorders

Diagnosticians recognize several subtypes or course specifiers:

Atypical depressionis characterized by mood reactivity (paradoxical anhedonia) and positivity, significantweight gainor increased appetite ("comfort eating"), excessive sleep or somnolence ( hypersomnia ), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceivedinterpersonal rejection .

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Psychotic depressionis the term for a major depressive episode, particularly of melancholic nature, where the patient experiences psychotic symptoms such asdelusionsor, less commonly,hallucinations . These are most commonly mood-congruent (content coincident with depressive themes).

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Catatonic depressionis a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here the person is mute and almost stuporose, and either immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur inschizophrenia , amanic episode , or be due toneuroleptic malignant syndrome .

Postpartum depressionis listed as a course specifier in DSM-IV-TR; it refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which has incidence rate of 1015%, typically sets in within three months oflabour , and lasts as long as three months

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Seasonal affective disorderis a specifier. Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times over a two-year period or longer.

Dysthymia , which is a chronic, milder mood disturbance where a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to secondary episodes of major depression (sometimes referred to asdouble depression ).

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Recurrent brief depression(RBD), distinguished from Major Depressive Disorder primarily by differences in duration. People with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 23 days. Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of themenstrual cycle . People with clinical depression can develop RBD, and vice versa, and both illnesses have similar risks.

Minor depression , which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.

23. Treatment

Treatment have those galls :

Risk Assessment

Ensure the safety of the patients

Ensure complete diagnostic evaluation

Ensure treatment of the immediate symptoms and the future of the patients.

Hospitalization :

For diagnostic evaluation, suicide and homicide risk, dehydration and starvation, loss of social support.

24. It is necessary that every patient, whom we suspect to have mood disorders,should be thoroughly assessed by careful and full history and mental state examination. The notes of the social worker and clinical psychologists should be studied too. The necessary investigations to exclude other possible causes should be done including full blood count, drug screening ,hormonal essays including thyroid function tests, EEG, CT scan and if necessary other neuroimaging techniques. 25. The line of management depends on whether the disorder is acute or chronic, bipolar unipolar, recurrent or a single episode.The choice of the treatment method should be made by discussion with the patient, his relatives and individual physician.The treatment methods include: PsychologicalPharmacologicalPhysical 26. Treatment

Psychosocial Therapy :

Cognitive therapy: was developed originally by Aaron Beck. Focuses on cognitive distortions postulated to be present in MDD. It works by helping patients identify and test negative cognitions; develop alternative, flexible, and positive ways of thinking; and rehearse new cognitive and behavioural responses.

Interpersonal therapy: was developed by Gerald Klerman, focuses on one or two of the patients current interpersonal problems. It is based on two assumptions. First, current interpersonal problems are likely tohave their roots in early dysfunctional relationships. Personality factors need to be addressed and does not deal with dynamics of the patients problems.

27. Treatment

Psychosocial Therapy :cont

Behaviour Therapy: is based on the hypothesis that maladaptive behavioural patterns result in a persons receiving little positive feedback and perhaps outright rejection from society.

Psychoanalytically Oriented Therapy: the aims include improvement in interpersonal trust, intimacy, coping mechanisms, the capacity to grieve and the ability to experience a wide range of emotions.

Family Therapy: is indicated if the disorder jeopardizes a patients marriage or family functioning or if the mood disorder is promoted or maintained by the family situation

28. Treatment

Pharmacotherapy :

All current available antidepressants may take up to 3 to 4 weeks to exert significant therapeutic effects.

Patient Education: patient should be educated about the illness, benefit of drugs, side effects. Avoid providing patients with large prescriptions due to the risk of suicide.

Alternatives to drug therapy: ECT is used when a patient is unresponsive to pharmacotherapy or the clinical situationis so severe that the rapid improvement seen with ECT is needed. Occasionally it is treatment of choice such as older depressed patients.Phototherapy use in seasonal mood disorder.

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Treatment should continue for at leas 6 months after remission.

Prophylactic treatment should be used in recurrent cases, suicidal ideation and impaired psychosocial functioning

Augmentation is used when treatment fails: Lithium, Liothyrnine, L tryptophan.

30. In mild depression psychotherapyis the first line treatment and pharmacological therapy is not recommended routinely as first line therapy.In moderate to sever depressionwhen other treatments for two weeks fail antidepressants should be first line treatment.Indysthymiaantidepressants could be used as first line treatment. 31. Tricyclic antidepressants:These drugs have many side effects including anticholinergic effects, hypotension and tachycardia and cardiac toxicity which makes them dangerous in toxicity and overdoses. Tricyclic antidepressants should not be used as first line treatment in mild to moderate depression.They arerecommended for severely ill inpatients. 32. Specific serotonin reuptake inhibitors : Including fluoxitine, paroxitine, fluvoxamine, citalopram, sertraline, escitalopram. They are recommended by NICE as first line pharmacological treatment of depression because they have less side effects compared to tricyclic antidepressants. They are relatively safer in overdoses. However they might lead to gastric irritation, nausea, vomiting, headache, increased anxiety and sexual dysfunction. 33. Specific serotonin reuptake inhibitors : They cause decreased arousal, drive and difficulty reaching orgasm. These side effects might lead to noncompliance.The initial increased anxiety might lead to suicide. 34. Monoamine oxidase inhibitorsMAOIs : They are used for atypical depression with reversed biological symptoms as increased appetite and weight. It is recommended by NICE for those who do not respond to SSRIs. The ireversible MAOIs have serious interaction with drugs and food containing tyramine. 35. Monoamine oxidase inhibitorsMAOIs : The reversible MAOIs as Meclobemide has less risk of interaction but therapeutically less effective.Those drugs lead to postural hypotension , overstimulation, sexual dysfunction, weight gain and possibly addiction. 36. Serotonin and noradrenaline reuptake inhibitors SNRIs: Venlafaxine and duloxetene.Venlafaxine is more potent than SSRIs and recommendedby NICE for severely depressed patients with monitoring the blood pressure.Doluxetene is not as potent as Venlafaxine and it might lead to initial nausea.Both drugs lead to nausea, hypertension, increased anxiety and sexual dysfunction . 37. Other antidepressants: reboxetene: is selective noradrenaline reuptake inhibitor. It has anticholinergic side effects and sexual dysfunction. Neverthelss it is well tolerated but evidence of its effectiveness is scarce.mirtazepine: is2 adrenoceptor antagonist. It cause sedation and weight gain. Therefore it liked by patients with insomnia and disliked by obese patients. 38. Other antidepressants: Mianserine is a tetracyclic drug and is 2 adrenoceptor antagonist. It is less popular now because of agranulocytosis. 39. Treatment resistant depression: Augmetation therapy: Antidep and psychtherapy Antidep and atypical antipsychotic Antidep and thyroid hormone 40. Mania 41. Defination

Mania is a Greek word meanmadness.

Theterm used to describe a syndrome involving sustained and pathological elevation of mood accompanied by other changes such as disturbances of physical energy , sleep and appetite with psychotic features.

42. Definition.. Contd

Bipolar Affective Disorder (BAD)

is an episodic illness , where periods of normal psychological functioning are interrupted at intervals by periods of either mania or depression.

43. Definition.. Contd

Bipolar 1 disorderpreviously called Manic Depressive Illness characterizes with episode of mania and depression or mania only.

Bipolar 2 disordercharacterized with depression and few hypomania episode.

44. Features of a Manic Episode

1.Emotional symptoms

Extreme irritability & distractibility .

Excessive "high" or euphoric feelings.

Emotional liability between anger and euphoria.

45. Features of a Manic Episode

2.Cognitive symptoms

Inflated self esteem and grandiosity.

Reported self confident, capable and can do things better than other.

Unrealistic belief in one's own abilities and achievement

Delusion of grandeur that they are famous, gift, and extraordinary.

Thought flow, flight of idea

Poor judgment regarding personal, social, occupation and activities.

46. Features of a Manic Episode

3.Behavioral symptoms

Increased talkativeness, agitation, excessive involvement in

pleasurable activities.

Wearing bright color, unusual dress & heavy makeup.

Productivity, creativeinvolves in projectwith negatives consequences.

Decreased sleep, Increased sex drive

Substance abuse.

Provocative or noxious behavior

Denial of problem.

47. Hypomania

Is somewhat similar to mania, a less extreme mood state, hypomania is defined as an elevated mood during which (1) no hospitalization has ever been necessary and (2) no state of delusional or other psychotic thinking ever coincided with the elevated mood.

Hypomania are not sever enough to cause impairment in social and occupational function.

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Hypomania may feel good to the person who experiences it. Thus, even when family and friends learn to recognize the mood swings, the individual often will deny that anything is wrong

Mixed affective episode

In the context of bipolar disorder, a mixed state is a condition during which symptoms ofmaniaandclinical depressionoccur simultaneously.

49. Treatment

1.Medications A. Mood stabilizer is the first line of treatment for manic episodes. E.g. Lithium

Mood regulators Anti-seizure medications, such as valproic acid (Depakene),and lamotrigine (Lamictal).

Antipsychotic medications such as risperidone (Risperdal), olanzapine (Zyprexa) orSeroquel.

50. Treatment.Contd Mood Stabilize Adverse Effects Special Concerns Lithium carbonate (Eskalith CR, Lithobid) Gastrointestinal distress, lethargy or sedation, tremor, Hypothyroidism, diabetes insipidus, renal diseasevalproic acid (Depakote, DepakeneSedation, platelet dysfunction, liver disease, alopecia, weight gainElevated liver enzymes or liver disease, drug-drug interactions, bone marrow suppressionCarbamazepine (Tegretol)Suppressed WBC, dizziness, drowsiness, rashes, liver toxicity (rarely)Drug-drug interactions, bone marrow suppression 51. Treatments

3. Electroconvulsive therapy (ECT) ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes.

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