Mood Disorders: A Biopsychosocial Approach

Katharine Gillis FRCPCAssociate ProfessorDepartment of PsychiatryUniversity of Ottawa

MOOD DISORDERS

Major Depressive Disorder Dysthymic Disorder Bipolar Disorders: I with Mania II with hypomania Cyclothymia

LIFETIMES PREVALENCES Major Depressive Disorder

women 10-25 %men 5-12%

Dysthymia 6 %

Bipolar Disorders type I 0.4-1.6 % type II 0.5%

In the Family Practice Setting 25% of all patients who visit their family

physicians will have a diagnosable mental disorder

The incidence of major depression is 10% in primary care patients

Effective treatment can reduce morbidity and decrease utilization of other health services

Medical patients with major depression have a worse prognosis for their medical recovery

Key Concepts in Mood Disorders

Mood Disorders are usually EPISODIC Need to inquire about current episode, but

also past episodes Past history of episodes that are high or low

are the often the key to sorting out the diagnosis

Genetics are very important in mood disorders especially Bipolar: ALWAYS ask about family history of mood symptoms or suicide

Key Concepts in Mood Disorders

Is there a history of inter episode wellness- better prognosis

Are the symptoms chronic Treatment goal is to treat current

symptoms but also to try and prevent future episodes of mood symptoms

Treatment usually medication based for moderate to severe symptoms plus or minus a specific type of psychotherapy.

How is Major Depression different from just feeling down?

Just feeling down should not have “physical symptoms” associated with it

Just feeling down should not impair function Just feeling down should not last daily for at

least two consecutive weeks or more Untreated an episode of major depression

on average lasts 6-12 months

Key Concept for Major Depression

For Major Depression must have persistent symptoms of depression or LOSS of INTEREST for at least 2 consecutive weeks

Many people with depression do NOT report feeling depressed, but have loss of interest

Elderly patients often have new onset of somatic complaints but may deny feeling depressed

Need a cluster of four other symptoms besides loss of interest or depression to make the diagnosis

Key Concept for Major Depression

Physical symptoms of depression include changes FROM BASELINE in sleep, appetite, energy and physical movements

Physical symptoms are often referred to as “vegetative symptoms”

The presence of new onset of vegetative symptoms can be a good predictor of response to antidepressant treatment

Physical Symptoms of Major Depression

Sleep- change from baseline. Usually too little.

All sleep phases can be effected but the classic symptom is early morning awakening.

Excessive sleep from baseline is an atypical feature and occurs more in teenagers

Physical Symptoms of Major Depression

Appetite-change from baseline usually a decrease

Loss of taste for food* Loss of weight Increase in appetite from baseline,

especially with carbohydrate craving is an atypical feature and occurs more in teenagers

Physical Symptoms of Major Depression

Fatigue- change from baseline Diminished spontaneous movements

may be observed and is called psychomotor slowing

Physical restlessness may be observed and is called psychomotor agitation

Other Important Symptoms of Major Depression

Guilt Impaired concentration Social withdrawal Suicidal thoughts: Safety assessment Panic attacks* Obsessive compulsive symptoms*

*Not in DSM-4 criteria

Specifiers for Mood Disorders

Specifiers describe the most recent mood episode such as:

With Postpartum Onset (within 4 weeks of delivery

With Catatonic features With Atypical Features With Rapid Cycling

Specifier- With Seasonal Pattern Only applies to Major Depressive Episode (not manic

or hypomanic) Regular temporal relationship between onset of major

depressive episode and a particular time of year usually fall or winter

Full remission also occurs at regular time of year usually spring (or switch to mania)

In the last 2 years two major depressive episodes have occurred as above with no nonseasonal episode of MDE occurring in the two years

Seasonal episodes of MDE outweigh nonseasonal episodes in their lifetime

Specifier-With Psychotic Features

Psychosis may be present in 10-15% of patients with a Major Depressive Episode

Associated with worse prognosis Increase risk of suicide and homicide Important to always screen for psychotic

symptoms Has treatment implications- antipsychotic

needs to be added to antidepressant. May be an indication to consider ECT.

Epidemiology of Major Depression. Who is at risk?

Prevalence for men 5-12%, women 10-25%

Mean age of onset is around 40 50% of all patients have onset between

the ages of 20 and 50 10% of post partum women are at risk of

Major Depressive Episode. Etiology remains unclear, stress vs. hormone

Epidemiology of Major Depression. Who is at risk?

No correlation between socioeconomic status and MDE but unemployed are at 3X more risk

MDE more common in rural than urban areas

Prevalence of mood disorder does not vary among races

Loss of a parent before age 11 is a risk Loss of a spouse is a risk

Recurrence Rates in Major Depression

After 1 episode 50 % After 2 episodes 75 % After 3 episodes 90 % +

DYSTHYMIA

Depressed mood most days for 2 years Depressed symptoms include: appetite disturbance sleep disorder fatigue low self-esteem poor concentration hopelessness indecision

DYSTHYMIA (cont.)

Never symptom-free for over 2 months

Symptoms cause impaired functioning Antidepressant may or may not be

helpful. Psychotherapy may help particularly if many negative cognitions.

Bipolar Disorder Bipolar disorder is characterized by the

occurrence of mood episodes, usually with inter-episode wellness.

A mood episode can be a major depressive, manic, hypomanic, or mixed episode

An episode is demarcated by either switch to an opposite state ( manic to depressive) or 2 months or more of partial or full remission after an episode

Bipolar Type I Prevalence 1% of population men=women Must have at least one Manic Episode Does not require a depressive episode but

most patients have depression in their lifetime

Most have more depressive than manic episodes

Manic episodes are not subtle and usually require hospitalization

Manic Episode Criteria Elevated mood (may be irritable, expansive)

persisting for at least one week Need 3 (or 4 if irritable) of the following:

Grandiosity Delusions Reduced sleep Talkative Racing thoughts (flight of ideas) Distractibility Psychomotor agitation Poor impulse control, excessive involvement in

pleasurable activities

Manic Episode Criteria

Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features

Symptoms present at least one week

Condition not caused by general medical condition or substances

Mixed Episode Criteria Criteria are met for both a manic episode

and a major depressive episode (except for duration) nearly every day for 1 week

Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features

Condition not caused by general medical condition or substances

Bipolar I Average onset for first manic episode is age

32 Most have had 2-3 episodes of depression

by history prior to first manic episode Symptoms of acute mania develop over

hours to days Untreated manic episode lasts 3 months Untreated depressive episode lasts 6-13

months

Bipolar II Must have hypomanic episode(s) not manic Prevalence 0.5 % population May have major depressive episodes Less functional impairment than Type 1 Often does not require hospitalization If patient looks hypomanic but delusions

present then diagnose as manic Did an antidepressant cause the hypomanic

symptoms? If so may be Bipolar III.

Hypomanic Episode Elevated, expansive or irritable mood

lasting at least 4 days Need 3 (or 4 if irritable) of the following:

Grandiosity Delusions Reduced sleep Talkative Racing thoughts (flight of ideas) Distractibility Psychomotor agitation Poor impulse control, excessive involvement in

pleasurable activities

Hypomanic Episode Unequivocal change in functioning from

baseline The disturbance in mood and the change in

functioning is observable by others The episode is NOT severe enough to cause

marked impairment in work or social functioning, or to need hospitalization, no psychotic features

Symptoms are not caused by a general medical condition or substances

Rapid Cycling Bipolar Disorder Can be applied to Bipolar I and II At least four mood episodes in previous 12

months- depression, mania, hypomania, mixed state

Episode demarcated by either switch to opposite state or 2 months of partial or full remission between episodes

Rapid cycling diagnosis has treatment implications

CYCLOTHYMIA

Numerous periods of depressive symptoms AND hypomania symptoms over 2 years

Never symptom free for 2 months No time of Major Depression or Mania Symptoms cause impaired functioning

Common Medical Conditions Associated with Mood Disorders

Hypo/hyper thyroidism Cardiovascular disease especially MI CNS- infection, tumour, stroke, head injury,

hypoxia Parkinson's, Huntington's, Multiple Sclerosis B12, folate deficiency Chronic pain Sleep Apnea

Drugs Commonly Associated with Mood Disorders

Steroids, corticosteroids – depression, mania, anxiety

Accutane isoretinoin Oral contraceptives, progesterone Interferon A Evidence for Beta Blockers is weak