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Mood Disorders
Dr.Issam Bannoura MD JB Psychiatry
Clinical tutor, Bethlehem Mental Hospital
The mood disorders are so called, because one of their main features is
abnormality of mood.
Mood may be normal, depressed or elevated.
The central features of those syndromes, called depressive disorders are
depressed mood, pessimistic thinking lack of enjoyment, reduced activity and
slowness. Those disorders are:
 Major depressive disorder
 Minor depressive disorder
 Recurrent brief depressive disorder
 Seasonal affective disorder
 Premenstrual dysphoric disorder
 Dysthymia
Syndrome in which the main features are elation, over activity, mood
change and self important ideas is often called Mania, and the less severe form
is called Hypomania. These disorders are:
 Bipolar I disorder (Manic depressive disorder)
 Bipolar II disorder
 Rapid cycling and mixed affective states
 Cyclothymia
Major depressive disorder
Clinical picture:
The central features of major depressive disorder are low mood, lack of
enjoyment, pessimistic thinking, and reduced energy, which leads to
decreased functioning.
The patients appearance is characteristic, dress and grooming may be
neglected, the patient sometimes may speak of a black cloud pervading all
mental activities.
Pessimistic thoughts are important, which can be concerned with past,
present or future. Lack of interest and enjoyment is frequent; the patient may
show no interest for activities, with reduced energy, psychomotor retardation,
anxiety, irritability and agitation, some of these symptoms may dominate the
clinical picture.
A group of symptoms called geological are important, these biological
symptoms include; sleep disturbance, early morning awakening, diurnal
variation of mood, loss of appetite, loss of weight, constipation, loss of libido,
and among women amenorrhea.
Sleep disturbance is of several kinds, most characteristic feature is early
morning awakening, but delay sleep and waking during sleep also occur.
Several other psychiatric symptoms may occur, they include;
depersonalization, obsessional symptoms, phobias, and dissociative symptoms
such as fugue. Complaints of poor concentration and poor memory also may
occur.
Types of depression:
1) Moderate depressive disorder: This disorder described above.
2) Severe depressive disorder: when depressive disorder becomes
severe, all features described above occur, with greater severity and
intensity. In addition other features may occur, in the form of delusions
and hallucinations, sometimes called psychotic depression.
3) Agitated depression: this term is applied to depressive disorder, in
which agitation is prominent. Agitated depression is seen more
commonly among the middle aged and elderly, than among younger
patients.
4) Retarded depression: this name is applied when psychomotor
retardation is prominent.
5) Depressive stupor: in some severe forms of depression, the patient
appears mute, motionless, immobile but aware of surroundings.
6) Masked depression: this term is applied when the depressive mood is
not clear, conspicuous, it is important to detect the loss of pleasure and
poor concentration.
7) Atypical depression: the term atypical has been applied to several
different clinical syndromes; it has included features such as variable
mood, phobic anxiety, overeating, and leaden paralysis.
8) Brief recurrent depression: some patients experience depressive
episodes of short duration, typically 2-5 days, about once a month on
average, they are associated with personal distress with social and
occupational impairment.
9) Mild depressive disorder: this syndrome would present with
symptoms similar to those of the major depressive disorder already
described, but with less intensity.
Classification of depressive disorders:
Classification based on etiology:
1. Reactive and endogenous depression: in endogenous disorders,
symptoms were caused by factors within the individual person, and
were independent of outside factors. In reactive disorders, symptoms
were a response to external stressors, and were sad to be characterized
by anxiety, irritability and phobias. In the other side endogenous
depression in characterized by biological symptoms.
2. Neurotic and psychotic depression: neurotic depression is used when
there is no evidence of loss of contact with reality, in the other side
psychotic depression is applied when delusions and hallucinations are
present in the course of disorder.
3. Melancholic and somatic depression: in which the most prominent
features are loss of interest and pleasure, distinct quality of mood,
morning worsening of mood, early morning waking, psychomotor
agitation or retardation, significant anorexia or weight loss, excessive
guilt and loss of libido.
4. Primary and secondary depression: This is based on etiology. The
aim was to exclude cases of depression that might be caused by another
disorder.
Classification by course and time of life:
1. Unipolar and bipolar disorder: Leonhard suggested a division of
affective disorders into three groups; patients who had had only a
depressive disorder called unipolar depression. Those who had had only
mania called unipolar mania, and those ho had had both depression and
mania called bipolar.
2. Seasonal affective disorder: some patients repeatedly develop a
depressive disorder at the same time of year; the characteristic features
of this syndrome are hypersomnia and increased appetite with craving
to carbohydrate. The most common pattern in onset in autumn or
winter, and recovery in spring or summer, this pattern has led to the
suggestion that shortening of day light is important, and to attempts at
treatment by exposure to bright artificial light during hours of darkness.
Improvements may be related to known effect of light in suppressing
the nocturnal secretion of melatonin.
3. Involutioanal depression: in the past, depressive disorders starting in
middle life were thought to be a separate group characterized by
agitation and hypochondriacal symptoms, it was suggested that they
might have a distinct etiology such as involution of sex glands.
4. Senile depression: elderly patient with depressive disorders were also
regarded as separate group.
Classification based on ICD 10 and DSM IV
-Major depressive disorder –mild
-moderate
-severe
-severe with psychoses
-Dysthymic disorder.
-Depressive disorder not otherwise specified
-recurrent brief depression
-minor depressive disorder
Diagnoses of depressive episode (DSM IV):
A. Five of the following (or more) have present at least for two weeks
period, symptoms (1) or (2) must always present:
(1) Depressed mood most of the day and every day.
(2) Diminished interest in pleasure activities.
(3) Significant weight loss or weight gain (Appetite change).
(4) Insomnia or hypersomnia.
(5) Psychomotor agitation or retardation.
(6) Fatigue or loss of energy.
(7) Feeling of guilt and worthlessness.
(8) Diminished ability to think and concentrate.
(9) Recurrent thoughts of death and or suicidal ideation.
B. The symptoms do not meet criteria for mixed episode.
C. Significant impairment in social and occupational functioning.
D. The symptoms are not due to GMS, or substance induced.
E. The symptoms are not due to bereavement.
The most recent type (severity):
1. Mild: minor impairment, no psychotic symptoms.
2. Moderate: moderate impairment may pass in some psychosis.
3. Severe: severe impairment passes in some psychosis.
4. Severe with psychosis: the clinical picture is dominated with psychotic
symptoms:
-Mood-congruent psychotic features: guilt, death, nihilism.
-Mood-incongruent psychotic features: persecutory, reference, thought
insertion, withdrawal and broadcasting.
Diagnoses of major depressive disorder (DSM IV):
A. Presence of at least one single depressive episode.
B. The episode is not due to schizophrenia, schizo-affective disorder,
schizophreniform disorder or delusional disorder.
C. Never been manic episode, mixed episode or hypomanic episode.
Special features that may associate the clinical picture:
-with catatonic features
-with melancholic features
-with atypical features
-with post partum onset
-with seasonal pattern
Diagnoses for minor depressive disorder:
The mood disturbance is defined the same as in depressive episode, but the
symptoms are less severe and for the diagnoses only two symptoms are
needed (less than five needed for major depression), in which symptoms (1) or
(2) previously described are a must, and the duration at least two weeks period
Diagnoses for recurrent brief depressive disorder:
The same criteria which are met for depressive episode, except the duration
is less than two weeks typically 2-5 days, needed for the diagnoses and the
episodes are repeated about once a month on average.
Premenstrual dysphoric disorder:
The pattern of symptoms occurs at a specific time during the menstrual
cycle, symptoms are present during the luteal phase, and began to remit during
menstruation. The criteria include abnormal behavior, mood and somatic
symptoms.
The most common symptoms are, liability of mood, anxiety, irritability,
fatigability, poor concentration, change in appetite and sleep, headache,
abdominal distention, breast tenderness and edema.
Dysthymic disorder:
The diagnoses criteria for dysthymia is the same as minor depressive
disorder, except the duration of symptoms are too long, two years for adults
and one year for adolescents and children. Dysthymia also called neurotic
depression; patients are often anxious, obsessive, and prone to somatization.
Some patients develop major depressive disorder in the course of their
dysthymic disorder, and are called to have double depression.
Mania
Clinical picture:
The central features of the syndrome of mania are elevation of mood,
increased activity, and self important ideas. The appearance reflects his
prevailing mood, clothes may be brightly colored, manic patients are
overactive their speech is often rapid, with flight of ideas or pressure of
thought, sleep is often reduced, appetite and sex are increased and uninhibited.
Expansive ideas are common; many patients become extravagant,
overspending, with reckless spending. Sometimes their expansive themes are
accompanied by grandiose delusions, hallucinations also occur, and insight is
invariable impaired.
Mixed affective states:
Depressive and manic symptoms sometimes occur at the same time, for
example a manic patient may become intensely depressed for few hours, and
then return quickly to his manic state.
Manic stupor:
In this unusual disorder, patients are mute immobile and motionless, but
their facial appearance and expression suggests elation.
Rapid cycling disorders or periodic psychoses:
Some bipolar disorders recur regularly, with intervals of only weeks or
months between episodes, usually at least four episodes of mania or
depression a year are needed for the diagnoses of rapid cycling disorder.
They are much more common among females.
Classification of bipolar disorders:
Manic episode----Mania- mild-severe
-severe with psychoses
----Hypomania
Bipolar disorders-Bipolar I disorder
-Bipolar II disorder
Cyclothymia.
Diagnostic criteria for manic episode (DSM IV):
A. Elevated, expansive, or irritable mood for at least one week.
B. During the mood disturbance, at least three or more of the following
(1) Inflated self esteem or grandiosity.
(2) Decreased need for sleep.
(3) More talkative than usual.
(4) Flight of ideas or pressure of thought.
(5) Distractibility.
(6) Increased activity.
(7) Excessive involvement in pleasure activities.
C. the symptoms do not meet criteria for mixed episode.
D. Marked impairment of social and occupational functioning.
E. The episode is not related to substance use, or due to GMC.
Severity: the most recent type:
Mild: minimum symptoms and no psychoses.
Moderate: increased activity and occasional psychoses
Severe: severe symptoms and psychotic features
Severe with psychoses: the psychotic symptoms dominate the clinical
picture—Mood-congruent psychotic features; grandiosity
-Mood-incongruent psychotic features; persecution
Diagnostic criteria for hypomanic episode (DSM IV):
The diagnostic criterion of hypomanic episode is similar to manic episode
with two main differences:
1-The duration of symptoms are less of one week needed for manic episode
2-The episode is not severe enough to cause marked impairment of social and
occupational functioning.
Diagnostic criteria for bipolar I disorder (DSM IV):
A: Presence of at least one manic episode, past depression is not needed.
B: The manic episode is not accounted for schizophrenia, schizo-affective
disorder, schizophreniform disorder, or delusional disorder.
The disorder may be associated with special features:
-with catatonic features
-with post-partum onset
-with seasonal pattern
-with rapid cycling
-with mixed episode
Diagnostic criteria for bipolar II disorder (DSM IV):
A: Presence of one or more depressive episode.
B: Presence of at least one hypomanic episode
C: Never been a manic episode.
D: Symptoms are not accounted for schizophrenia, schizo-affective disorder,
schizophreniform disorder or delusional disorder.
Cyclothymic disorder:
Cyclothymic disorder is symptomatically is a mild form of Bipolar II
disorder, it is characterized by alternation of episodes of hypomania and
episodes of minor depressive disorder, with long duration of time, at least two
years for adults, and one year for adolescents and children, with no remission
period for at least two months.
Epidemiology of mood disorders:
Disorder
Prevalence
Sex f : m
Mean age of onset
Social class
Major depressive
6-10%
2:1
27 years
low
Bipolar I
1%
1: 1
21 years
high
Etiology of mood disorders:
Genetic causes:
Genetic data, and several genetic family, adoption, and twin studies,
indicate that a significant genetic factor play roll in the development of mood
disorders. In addition there is a stronger genetic component for the
transmission of bipolar I disorder, than that of the depressive disorder.
The concordance rate in twin studies for bipolar I disorder is 69MZ to
13DZ, and for depression 55MZ to 15DZ. The mode of inheritance is not
clear yet.
Environmental causes:
Predisposing factors that may play roll are:
1-Many studies suggested that childhood deprivation, through separation or
loss predisposes to depressive disorders in adult life.
2-Parents of depressed patients have been described as less caring, and more
overprotective.
3-Unhappy marriage.
4-Problems at work
5-Unsatisfactory housing
6-Low self-esteem and poor social support
7-Brown and Harris studied four vulnerable factors for women:
-having the care of three or more young children
-not working outside home
-having no one to confine in
-loss of mother by death or separation before the age of 11
Recent life events may play major roll as precipitating factors, there is an
excess of life events in the months before the onset of depressive disorder,
also it has been suggested that loss by separation or death is particularly
important.
Biological factors:
The monoamine hypothesis suggests that depressive disorder is due to an
abnormality in the monoamine neurotransmitters system, at one or more sites
in the brain. Three monoamine transmitters have been implicated:
-5hydroxytryptamine (5HT) or serotonin
-Noradrenalin (NA)
-Dopamine (D)
-Others, such as GABA and vasopressin
The hypothesis has been tested by observing three kinds of phenomena:
1- Low levels of metabolites (5HIAA, 3M4HPG) are detected in blood, urine,
and CSF of depressive patients, and increased dopamine metabolite (HVA)
in mania.
2- The effects of selective drugs, and the pharmacological proprieties shared
by antidepressant drugs.
3-The studies of post-mortem brain, that the density of neurotransmitters
receptors in certain cortical regions is changed, in patients with mood
disorders that can be an adaptive or compensation change.
Neuroendocrinal causes:
1- The hypothalamus is central to the regulation of endocrine axis, and itself
receives many neuronal inputs, that use biogenic amine neurotransmitters.
The major neuroendocrine axis of interest:
-Adrenal axis: hypersecretion of cortisol in depression
-Thyroid axis: blunted release of thyrytropine in depression
-Growth hormone: blunted growth hormone release in depression
2- Sleep abnormalities; common abnormalities are:
-delay sleep onset
-shortened REM latency
-increased length of first REM period
-impaired sleep continuity and duration
-decreased deep sleep (stages III and IV)
These sleep abnormalities are suggesting that Melatonin secretion is
decreased, as a marker of circadian rhythm deregulation.
3- Kindling theory is the electrophysiological process in which repeated sub
threshold stimulation of a neuron, eventually generates an action potential,
that led to the theory of kindling in the temporal lobe may cause manic
symptoms. And the clinical observation that anticonvulsants (Carbamazepine,
Depakin) are useful in the treatment of mood disorders, rise and support that
theory.
Neuroanatomical considerations:
Brains imaging (CT, MRI, PET, and SPECT) have provided a number of
abnormal brain functions of patients with mood disorders. The data indicate
the following: -Enlargement lateral ventricles in bipolar I disorder
-Patients with major depression have smaller caudate nuclei
and smaller frontal lobes
-Mood pathology involves the limbic system, basal ganglia
and the hypothalamus.
Physique and personality:
Kretchmer (1936) proposed that patients of picnic body built were prone to
develop mood disorders
Kraeplin suggested that people with cyclothimic personality were more
prone to develop manic depressive disorder.
Psychological theories of etiology:
1- Psychoanalytic theory:
Freud in 1917 developed a paper called “mourning and melancholia” he
suggested that as mourning results from loss by death, the same melancholia
results from loss of other kinds. Freud termed the loss of an object, as main
cause of depression.
Klein 1934 suggested that at the early stage of development, the infant,
gradually when mother leaves him, he proposed the depressive position, if this
stage is not passed successfully; the child will be more likely to develop
depression in adult life.
Psychoanalytic theory explains mania as a defense mechanism against
depression.
2- Learned helplessness:
Seligman suggested that repeated unacceptable stimulation, may lead to
helplessness and depression.
3- Cognitive theory:
Beck has proposed that depressive cognitions consist of automatic
thoughts, may reveal negative views of self, word and future.
4- Behavior theory:
According to classical conditioning theory, developed by Pavlov, a person
may respond to stressful life events by depressive or manic symptoms.
Course and prognoses
Bipolar disorders:
Bipolar I disorder most often starts with depression (90%), and is a
recurring disorder, most patients experience both depressive and manic
episodes, although 10%-20% experience only manic episodes. Manic episode
may have a rapid onset, with duration over few weeks, untreated lasts about
three months. As the disorder progresses, the time between episodes often
decreases, after about five episodes, the interepisode interval stabilizes at six
to nine months. Some patients have rapidly cycling episodes. Patients with
bipolar I disorder have a poorer prognoses than do patients with major
depressive disorder.
Good prognostic features:-short duration of manic episode
-advanced age of onset
-few suicidal thoughts
-few coexisting psychiatric or medical problems
Poor prognostic features: -poor premorbid occupational status
-alcohol dependence
-psychotic symptoms
-male gender
Major depressive disorder:
The age of onset is later than in bipolar I disorder (27- 40 years). The
course is variable, untreated lasts 6- 13 months, most treated last about three
months. As the course of the disorder progresses, patients tend to have more
frequent episodes that last longer. It tends to be a chronic disorder, only 50%
have a chance of recovery in the first year, 10 – 20% have not recovered. By
time a patient experiences more and more depressive episodes, the time
between episodes decreases, the severity of each episode increases.
Good prognostic features: -mild episodes
-absence of psychotic symptoms
-short hospital stay
-good social functioning
-stable family functioning
-absence of premorbid psychiatric illness
-absence of premorbid personality disorder
Poor prognostic features: -coexisting dysthymic disorder
-abuse of alcohol or other substances
-coexisting anxiety disorder
-previous psychiatric disorder
Mood disorders and suicide:
Between 11 and 17 per cent of people who have suffered a severe
depressive disorder, at any time will eventually commit suicide.
Suicide is more common for male gender, older age, single, or separated,
divorced, unemployed, with previous suicidal attempts, with social isolation,
with premorbid personality disorder, past forensic history and with alcohol
and drug abuse.
Circumstances that suggesting high suicidal intent:
1-planning the act
2-precautions are taken to prevent discovery
3-no attempts are taken to obtain help afterwards
4-using dangerous methods
5-final act: writing a suicidal note or a will.
Differential diagnoses:
Major depressive disorder:
Depressed patients should be differentiated from other medical disorders, such
as: - temporal lobe epilepsy
-mononucleosis
-cerebrovascular disease
-dementias
-infectious diseases including HIV
-Cushing and Addison disease
-hypothyroidism
-hyperparathyroidism
-premenstrual depressive symptoms
Also depressive disorder should be differentiated from substance induced
depression, such as: cardiac drugs, antihypertensive drugs, sedatives,
hypnotics, antipsychotics, antiepileptics, antiparkinsonian, analgesics,
antibacterials, and antineoplastics.
Depression can be a feature of many mental disorders, such as:
1-other mood disorders
2-psychotic disorders
3-anxiety disorders
4-uncomplicated bereavement
Bipolar I disorder:
Manic episodes have to be distinguished from schizophrenia, schizoaffective disorder, organic brain disorder involving the frontal lobe, and states
of excitement induced by amphetamine, alcohol, cocaine, opoids, or other
drugs.
Treatment of mood disorders
Treatment of depression:
- Antidepressant drugs such as: -tricyclic antidepressants
-MAOI
-SSRI
-Lithium
-Anticonvulsants
-Electroconvulsive therapy (ECT)
-Psychotherapy
Treatment of mania:
-Antipsychotic drugs
-Lithium
-Anticonvulsants
-Electroconvulsive therapy (ECT)
-Psychotherapy
Acute treatment of depression:
The use of pharmacotherapy approximately doubles the chance that a
depressed patient will recover in one month. Generally it will take 2-4 weeks
to exert significant therapeutic effects. Patients may show the effect of
treatment earlier, the first symptoms to improve are; poor sleep, and appetite
pattern. The duration of antidepressant treatment is at least six months.
1- Cyclic antidepressants:
-Tricyclic - Imipramin (Tofranil) in dose 75-250 mg daily
- Amitriptylline (Elatrol) in dose 75-250 mg daily
- Clomipramin (Anafranil) in dose 75-250 mg daily
- Trimipramin (surmontil) in dose 75-250 mg daily
-Bicyclic, Desipramin, Nortriptylline, Protriptylline.
-Tetracyclic; Maprotilline, Amoxapine, Mianserine.
Side effect profile of cyclic antidepressants:
- anticholinergic
- sedation
-hypotension
-seizures
-cardiac changes
-toxic in high doses
2- Monoamineoxidase inhibitors (MAOIs) : they are effective in the treatment
of depression with melancholic features, wild form, and atypical
depression. MAOI drugs;
- Phenelzine (Nardil) in dose 15-60 mg daily
- Tranylcypromine (Parnate) 10-30 mg daily
- Moclobemide (Mobemide) 300 mg daily
Unwanted effects of MAOIs:
- anticholinergic
-hypotension
-cardiac effects
-edema of the ankle
-jaundice
-tyramine reaction, or cheese reaction, patients should avoid some foods and
drinks: - all cheeses except cream cheese
- red wine, been, liquors
-pickled or smoked fish
-packed soups
-beef and chicken livers
-some sausage
-aged, unfresh food
3-Selective serotonin reuptake inhibitors: (SSRI)
The SSRIs have minimal effects on blood pressure and cardiac function.
The major unwanted effects are nausea, anorexia and diarrhea, sometimes
weight loss. They have no anticholinergic side effects, and not toxic in
overdose, the most important SSRIs are
- Flouxetine (Prozac) in dose about 20 mg daily
- Fluvoxamine (Favoxil) in dose about 100 mg daily
- Paroxetine (seroxat) in dose about 20 mg daily
- Sertaline (Zoloft) in doze about 50 mg daily
- Cipram (Cipramil) in dose 20 mg daily
4- Lithium carbonate:
Studies have shown that Lithium has antidepressant effects, but the onset
of action is slower, and the serum level of lithium must be between 0.8-1.2
mEg/L. It has been reported that the therapeutic effects of tricyclic
antidepressants can be increased if lithium is added.
Unwanted effects of lithium:
- Tremors, dry mouth and metallic taste.
- Muscular weakness and fatigue
- Polyuria, polydipsia, diabetes inspidus
- Weight gain, edema
- Hypothyroidism, hyperparathyroidism
- Hypokalemia and ECG changes
- Anorexia, nausea and vomiting
- Leococitosis
- Structural renal tubular change and damage
- Toxic effects in overdose, the dose are over 1.5
mEg/L and include ataxia, poor coordination,
muscle twitching, slurred speech and confusion.
- Congenital malformation (teratogenic)
5-Anticonvulsant drugs: they can be used for depression, such as
-Carbamazepine (Tegretol) in dose about 600-1200 mg daily
-Sodium Valporate (Depalept) in dose of 20 mg/Kg body
6- Bright light treatment for atypical depression
7- ECT therapy: indications
- Severe depressive disorder
-Weight loss and early morning awakening
-Psychomotor retardation and delusions
8- Psychotherapy: the most important methods are
-clinical management
-supportive psychotherapy
-dynamic psychotherapy
-marital therapy
-interpersonal therapy
-cognitive behavior therapy
Acute treatment of mania:
1- Antipsychotic drugs, particularly chlorpromazine and haloperidol are
widely used to treat mania. The current trend in the management of mania is
to use lower doses of antipsychotic drugs, such as:
CPZ (Largactil) 300-500 mg daily
Halidol
6-20 mg daily
If addition sedation is needed, adjunctive treatment with a benzodiazepine
such as Lorazepan can be given.
2-Lithium Carbonate also can be used in the treatment of mania, alone or
adjunctive treatment with antipsychotic drugs, the main affect to decrease the
elevated mood.
3- Anticonvulsant drugs: Carbamazepine is effective in the treatment of acute
mania, and has earlier onset of action. The same Sodium Valporate in doses of
20 mg/kg body is effective in treatment of acute mania without psychoses.
4- ECT: ECT is superior to Lithium and anticonvulsant drugs in treatment of
mania. There is a tendency to give ECT to patients who are unresponsive to
drug treatment, with life threatening, extreme over activity and physical
exhaustion.
Prevention of relapse:
Unipolar depression:
For depression continuation of treatment for six months with
antidepressants has been shown to reduce the relapse rate. If antidepressants
are continued for longer period of time as prophylactic treatment they reduce
the risk of new episode of depression. Lithium in doses 0.6-0.8 mEg/L is also
effective in the prevention of depression.
Bipolar disorders:
There is substantial evidence for the efficacy of Lithium, Carbamazepine,
and Sodium Valporate in the prevention of mood disturbance in patients with
bipolar disorders.
To reduce the rate of relapses the duration of treatment is two years for one
episode, five years for two episodes and long life for more than three
episodes.
Further readings: - Oxford textbook of psychiatry
-Comprehensive textbook of psychiatry