Download Mood Disorders

Mood disorders
Psychiatry
Dr.Banaz Adnan
Aims of the Lecture
This 3 hour lecture has been given at the fifth year psychiatry course with the aim students can define terms
Mood, Affect and it's disorders, also able to know symptoms of both depressive and bipolar disorders, their
etiology and lines of management, with the hope you as student ,resident doctor can recognize cases of mood
disorder and able to help them .
Lecture outlines
1st Hour;
Definition of mood,affect,mood disorder
Definition ,C/F,etiology,Diagnosis,Differential diagnosis,prognosis of unipolar depressive disorder
2nd Hour:
Management of depressive disorder
3rd Hour
Definition,C/F,Diagnosis,Etiology,Course,Management of Bipolar affective disorder
In psychiatry two terms are used to refer to an emotional state--Mood & Affect
Mood; is a pervasive and sustained feeling tone that is experienced internally and that, in the extreme, can markedly
influence virtually all aspects of a person's behavior and perception of the world.
In psychiatric disorders, mood may be abnormal in three ways:
 Its nature may be altered; these can be towards anxiety, depression, elation, or irritability.
 It may fluctuate more or less than usual.
 It may be inconsistent with the patient's thoughts or actions or with his current circumstances.
Affect; is the external expression of the internal feeling tone.
Healthy persons experience a wide range of moods and have an equally large repertoire of affective expressions: they
feel in control of their moods and affects.
Mood (affective) disorders
For nearly 2500 years mood disorders have been described as the most common
diseases of mankind, but only recently have they commanded major public health
interest. The World Health Organization has ranked depression fourth in a list of the
most urgent health problems worldwide.
Defintion
Mood disorders re so called because one of their main features is abnormality of mood.
Known in previous editions of DSM as affective disorders, the
term mood disorders is preferred today because it refers to sustained emotional
states, not merely to the external (affective) expression of the present emotional
state.
Mood disorders are best considered as syndromes (rather than discrete
diseases) consisting of a cluster of signs and symptoms sustained over a period of
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weeks to months, that represent a marked departure from a person's habitual
functioning and tend to recur, often in periodic or cyclical fashion
Mood disorders are common disorders and have been divided into 2 major groups: Unipolar depressive disorders, in which the person only ever has depressive episodes.
 Bipolar affective disorders, in which the person has periods of elevated mood and also
(although not invariably) experiences episodes of depression.
Unipolar depressive disorder
 When depression occurs alone with no previous episodes of mania or hypomania.
 Depressive disorder has significant morbidity and mortality. About two thirds of all depressed
patients contemplate suicide and 10 to 15 % percent commit suicide.
 The term Depression mean “reduced functioning" or in other disciplines to be associated with
“Mental depression
Epidemiology
Prevalence
Depressive disorders are common, in most recent surveys, major depressive disorder has the highest
lifetime prevalence of any psychiatric disorder, with a prevalence of 5-10% in primary care settings.
They rank fourth as causes of disability worldwide, and it has been projected that they may rank
second by the year 2020.
The prevalence of depressive symptoms may be as high as 30% in the general population.
Lifetime rate of depression is about 10-20%(but very variable across populations).
The 6-month prevalence of major depression is between 2 and 5%.
Sex
 An almost universal observation, independent of country or culture, is the twofold greater
prevalence of major depression in women than in men. The reasons for the difference are
hypothesized to involve;
 Hormonal differences
 The effects of childbirth
 The effect of psychosocial stressor for women and for men
 Behavioral models of learned helplessness
Age
50% of all patients having an onset between the ages of 20 and 50.
Major depression can also begin in childhood or elderly.
Marital Status
Major depression occurs most often in persons without close interpersonal relationship or in those
who are divorced or separated.
Socioeconomic
No correlation has been found between socioeconomic status and major depressive disorder.
Rates of depression are higher in the unemployed.
Depression is more common in rural areas than in urban areas.
Clinical Features:
The following features are the common features in all depressive illness but their presence or absence
and severity varies.
1-Mood:
●The mood of the patient is one of the misery.
●The mood does not improve in circumstances where ordinary feelings of sadness would be
alleviated.
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●Diurnal variation of mood(the mood worsen in the morning when awake, improving a little as the
day wears on)
2-Depressive cognitions
Negative thoughts are important symptoms which can be divided in to;
 Worthlessness; the patient thinks that he is failing in everything, that he does and that other people
see him as a failure.
 Pessimistic thoughts concerns future prospects
 Feeling of guilt take the form of unreasonable self-blame about minor matters
3-Goal directed behavior
Lack of interest and enjoyment (anhedonia);the patient show no enthusiasm for activities and hobbies
that he would normally enjoy.
He often withdraw from social activities
Reduced energy is characteristic
The patient feel lethargic, finds everything an effort, and leaves tasks unfinished. Understandably,
many patients attribute this lack of energy to physical illness.
4-Psychomotor changes
 Retardation: In more sever depression the patient thinks ,walks and acts slowly.
 Agitation: is a state of restlessness that is experienced by the patient as inability to relax and is seen
by the observer as restless activity.
5-Biological symptoms
o Sleep disturbance; is of several kinds. Most characteristic is early morning wakening .Some
depressed patients sleep excessively rather than wake early.
o Diurnal variation (worse in the morning)
o Poor appetite and weight loss.
o Loss of libido in men and among women amenorrhea.
o Physical symptoms; complaints of constipation, fatigue, and aching discomfort anywhere in the
body are common.
6-Other features
Several other psychiatric symptoms may occur as part of a depressive disorder, they include
obssessional symptoms, panic attack, conversional symptoms.
Complaints of poor memory are also common. Because of the inability to concentrate so difficulty in
registering new memories (pseudodementia).
7-Appearance
The patient's appearance is characteristic.
Dress and grooming may be neglected.
Turning downwards of the corners of the mouth and vertical furrowing of the center of the brow.
The rate of blinking is reduced.
The direction of the gaze is downwards.
DSM-IV Criteria of Major Depressive Episode
A- Five (or more) of the following symptoms under criterion (A) have been present during the same 2
weeks period and represent a change from previous functioning and at least one of the symptoms is
present either (1)depressed mood or (2) loss of interest or pleasure.
1-Depressed mood most of the day, nearly every day.
2-Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly
every day.
3-Significant weight loss when not dieting or weight gain ,or decrease or increase in appetite.
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4-Insomnia or hypersomnia
5-Psychomotor agitation or retardation
6-Fatigue or loss of energy
7-Feelings of worthlessness or excessive or inappropriate guilt
8-Diminished ability to think or concentrate, or indecisiveness
9-Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide.
B- The symptoms do not meet criteria for a mixed episode (manic-depressive).
C-Marked socioccuptional impairment.
D- Exclude mood disorder due to general medical condition (e.g., hypothyroidism) or substance
induced.
E- The symptoms are not due to the loss of a loved one (bereavement).
DSM IV Classification of major depressive episode
Major depressive disorder
 Single episode
 Recurrent episode
The following specifiers apply for single episode:A-Severity
Mild;few symptoms results in only minor impairment in occupational and social functioning.
Moderat;symptoms or functional impairment between" mild "and "sever".
Sever without psychotic features; several symptoms in excess of those required to make the
diagnosis, and symptoms markedly interfere with occupational and social functioning.
Sever with psychotic features; In sever depression, certain distinctive features may occur in the
form of delusions and hallucinations; the disorder is then sometimes called psychotic depression.
The delusions of sever depressive disorder are mood congruent e.g. delusion of guilt,
hypochondrical, nihilistic.
Some depressed patients experience delusions and hallucinations that are not clearly related to
themes of depression (mood-incongruent).
B--Chronic
C--With Melancholic features; is some times referred to as "endogenous depression" or depression
that arises in the absence of external life stressor.
Is a depression characterized by sever anhedonia, early morning awakening, weight loss, and
profound feeling of guilt.
D--With catatonic features; like stuporousness, blunted affect, extreme withdrawal, negativisim, and
marked psychomotor retardation
E--With atypical features; like hypersomnia, significant weight gain or increase in appetite, leaden
paralysis(heavy, leaden feeling in arms or legs).
F--With Postpartum onset ; The onset of symptoms is with in 4 weeks postpartum.
G. With or without Inter episode Recovery
H. With Seasonal Pattern
Aetiology of Depression:
1-Psychosocial Factors;
o Life events and Environmental Stress;
The life event most often associated with development of depression is losing a parent before age
11.
The environmental stressor most often associated with depression is the lose of spouse.
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Another risk factor is unemployment; persons out of work are three times more likely to report
symptoms of depression than those who are employed.
○Personality Factors; persons with certain personality disorders -obsessive compulsive
personality, histrionic and borderline may be at greater risk for depression than other types of
personality.
2-Biological Factors:
o Genetic influence; family, adoption, and twin studies have long documented the heritability of
mood disorders. The rate of illness in the family members of someone with the disorder greater than
that of the general population. According to family studies the more members of the family who are
affected, the greater the risk is to a child.
According to twin studies, the concordance rate in unipolar depression is greater in monozygotic twins
(46%) than dizygotic twins (20%).
o The amine theory: The discovery that all antidepressants increase
monoamines((serotonin,noradrenaline,and dopamine ) release and /or reduce their reuptake in
the synaptic cleft, led to the development of the monoamine theory of Depression, which
suggests that reduced monoamine function may cause depression. Blunted neuroendocrine
responses and symptom induction by tryptophan depletion(5HT precursor)suggest an important
role for 5HT.
o Endocrine abnormality:Abnormalties in endocrine function may be important in aetiology for three
reasons:1) Hormones modulate the activity of monoamine neurotransmitters and could play a part in
producing some of the changes in monoamine function found in depressed patients.
2) Endocrine abnormalities found in depressive disorder indicate that there may be a disorder of the
hypothalamic centers controlling the endocrine system
3) Some disorders of endocrine function are followed by depressive disorders.
Endocrine changes found in depression are
- Blunted prolactine and growth hormone responses to tryptophan.
- Blunted TSH response to intravenous thyrotrophine releasing hormone(TRH).
-Increased cortisol in 50% of patients associated with adrenal hypertrophy, and dexamethasone
non suppression of cortisol.
o Structural and functional brain changes; changes in brain volume: CT,MRI have found a number
of abnormalities in patients with major depression, particularly in those with more sever and chronic
disorders, the most consistent findings are:
 Enlarged lateral ventricles.
 Volume loss in frontal and temporal lobe.
 Decreased hippocampal volume.
 Decreased volume of basal ganglia structures.
3-Cognitive theories;
Depressed patients characteristically have negative thoughts. Beck proposed that these depressive
cognitions consist of automatic thoughts that reveal negative views of the self, the world ,and the
future. These automatic thoughts appear to be sustained by illogical ways of thinking which called
cognitive distortions. e.g. of these distortions are;
selective abstraction: focus on a single detail while ignoring other, or important aspects of an
experience.
Overgeneralization: forming conclusions based on too little and too narrow experience
personalization: tendency to self reference external events without basis
Maximization and Minimization; over or undervaluing the significance of event
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Differential diagnosis
1-Normal sadness; It is part of normal experience to feel unhappy at times of adversity. The
distinction from normal sadness is made on the presence of other symptoms of the syndrome of
depressive disorder.
2-Anxiety disorders; mild depressive disorders are sometime difficult to distinguish from anxiety
disorders. Accurate diagnosis depends on assessment of the relative severity of anxiety and depressive
symptoms, and on the order in which they appeared. Similar problems arise when there are prominent
phobic or obssessional symptoms,or when there are dissociative symptoms with or without histrionic
behavior.
3-Schizophrenia; difficult diagnostic problems may arise when the patient has depressive psychosis,
the distinction can be made on mental state examination, and on the order in which symptoms
appeared.Information about past psychiatric history also may be useful.
4-Dementia;In middle and late life, depressive disorder are sometimes difficult to distinguish from
dementia because some patients with depressive symptoms complain of considerable difficulty in
remembering(pseudodementia) and distinction between the two conditions purely in terms of the
nature of memory impairment may not be possible.
Clinicians can usually differentiate the pseudodementia of major depression from the dementia of
disease on clinical grounds(presence of depressive symptoms is the key to diagnosis).
The cognitive symptoms in major depression have a sudden onset. Depressed patients with cognitive
difficulties often do not try to answer questions (I don't know); where as patients with dementia may
confabulate.
5. Other organic conditions like infections, neurological disorders, endocrine disorders..The key to
diagnosis is a careful history and physical examination.
Prognosis
Patients who have been hospitalized for a first episode of major depressive episode have a
50% chance of recovering in the first year.
25% of patients experience a recurrence in the first 6 month after release from hospital, 3050% in the first 2 year, and about 50-70% in 5 year.
Prognostic factors;
Good prognostic factors; Acute onset, mild episodes, the absence of psychotic symptoms, stable
family functioning, sound social functioning for the 5 years preceding the illness, absence of a
comorbid psychiatric disorders, and of a personality disorder, no more than one previous
hospitalization for major depressive disorder.
Mortality
 Suicide rates for sever depressive episodes vary but may be up to 13%(i.e. up to 20 times more
likely than the general population)
 The overall death rate for patients with depression is higher than the general population with the
cause of death usually due to suicide, drug and alcohol problems, accidents, cardiovascular
disease, respiratory infections.
Management of the Acute Phase:
 General Assessment: Routine History taking, physical examination then admission if:
o Risk of suicide
o Deteriorated physical condition because of refusal to eat or drink.
o Moderate to Severe depression.
o Psychotic depression.
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 Medications:
 Antidepressants: are chosen according to:
o Symptomatology ;
o sleep problems(more sedative agents),lack of energy/ hypersomnia (less sedative agents),risk of
suicide(avoid Tricyclic antidepressant)
o The patient's characters ;Age, sex, comorbid physical illness(such as cardiac disease, epilepsy)
and previous response to treatment.
Basic principles of prescribing medication in depression
 Discuss with the patient choice of drug and utility/availability of other non-pharmacological
treatments
Psycho educations: Discuss with the patient that the antidepressant effect may be delayed for
several weeks while relief of anorexia and sleep starts earlier.
 For a single episode, continue treatment for at least 6-9months after resolution of symptoms
(multi episodes may require longer).
 Withdraw antidepressant gradually because they can cause withdrawal reactions. All patients
should be informed about the withdrawal effects of antidepressants.
Antidepressant groups: The major categories of antidepressants are (on the basis of chemical
structure or presumed pharmacological mechanism of action:
1)Tricyclic antidepressants (TCAs)
2) Monoamine oxidase inhibitors (MAOIs)
3) Selective serotonin reuptake inhibitors (SSRIs)
4) Other antidepressants
Clinical guide lines:
All antidepressants are considered equally effective in treating major depression but differ in
safety and side effect profiles.
About 70% of patients with major depression will respond to antidepressant medication
(Efficacy).
Antidepressants have no abuse potential.
Older antidepressants (Tricyclics) are extremely dangerous when an overdose is ingested.(are
cardiotoxic in overdose)
If there is no response to treatment after 4-6 wks, or the patient can not tolerate switch to another.
Tricyclic antidepressant
They have a three-ringed structure with an attached side chain. TCAs inhibit the re-uptake of both
5-HT and Nor-adrenaline.
They also have antagonistic activities at a variety of neurotransmitter receptors .In general these
receptor blocking actions have been thought to cause adverse effects.
Classification of TCAs:
■ Tertiary amines: e.g.Imipramine (Tofranil), Amitriptyline (Tryptizol), Doxepin,
Clomipramine (Anafranil)—have a higher affinity for the 5-HT uptake sites and are more potent
antagonists of adrenoreceptors and muscarinic cholinergic receptors.
� Secondary amines: Desipramine, Nortriptyline, protriptyline.
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Dose of TCAs:
Minimum effective antidepressant dose is at least 75-100mg/day,and the
therapeutic range is between (150-300).
Side Effects:
1. Antihistaminic properties:Sedation, weight gain.
2. Antiadrenergic properties: drowsiness, postural hypotension, sexual dysfunction, cognitive
impairment.
3. Antimuscarinic effects: Dry mouth, constipation, urinary retention, blurred vision,
tachycardia.
4.Quindine-like membrane stabilizing effects: Cardiac conduction defects, cardiac arrhythmias,
epileptic seizures.
Serotonin reuptake inhibitors (SSRIs)
SSRIs inhibit the reuptake of serotonin with high affinity and selectivity, leading to increased
availability of serotonin in synaptic clefts; they have less affinity for other monoamine
neurotransmitter receptors.
They are the most commonly prescribed antidepressants due to several distinct advantages:
�Lack cardiotoxicity .
� No food restrictions (unlike MAOIs which will be discussed later)
� Much safer in overdose, simple dosing schedule.
Examples of SSRIs
Fluoxetine --- longest half-life with active metabolites.
Dose range --20-60 mg/day)
Sertraline — Dose range (50-200 mg/day).
Paroxetine —Dose range (20-50 mg/day)
Fluvoxamine ---Dose range(100-300mg/day)
Citalopram — Dose range (20-60 mg/day)
Escitalopram— Dose range (10-20 mg/day.
Side effects of SSRIs ;include: GIT disturbances(nausea, vomiting) ,agitation, appetite loss,
headache
diarrhea, insomnia, sexual dysfunction.
Monoamine Oxidase Inhibitors (MAOIs):
MAOIs prevent the inactivation of biogenic amines such as norepinephrine, serotonin,
dopamine, and tyramine (an intermediate in the conversion of tyrosine to norepinephrine).By
inhibiting the enzymes MAO-A and -B, MAOIs increase the amount of these transmitters
available in synapses.
Examples;
Phenelzine, Isocarboxazid,Tranylcypromine,Moclobemide
Side effects:
� Common side effects: Orthostatic hypotension, drowsiness, weight gain, sexual
dysfunction, dry mouth, sleep dysfunction.
� Serotonin syndrome occurs when SSRIs and MAOIs are taken together. Initially
characterized by lethargy, restlessness, confusion, flushing, diaphoresis, tremor, and
myoclonic jerks. May progress to hyperthermia, hypertonicity, rhabdomyolysis, renal
failure, convulsions, coma, and death.
� Hypertensive crisis: Risk when MAOIs are taken with food containing tyramine or
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sympathomimetics. Foods with tyramine (red wine, cheese, chicken liver, fava beans,cured
meats)
cause a buildup of stored catecholamines,so their use requires very careful dietary restrictions and
intense caution before combine with other drugs.
In practice MAOIs are very rarely used as first line treatment for depression.
Other Antidepressants:
Trazodone: Is serotonin antagonist/reuptake inhibitors(SARIs).
Side effects; markedly sedating, minimal anticholinergic effects. priapism.
Nefazodone:Is a 5HT receptor antagonist and modest 5HT reuptake inhibitor.
S/E; Sedation ,headache,dry mouth.
Bupropion ;Nor adrenaline and dopamine reuptake inhibitor.
S/E:Agitation,insomnia,dry mouth, GIT upset, risk of seizures, hypertension.
Venlafaxine: is serotonin/noradrenaline reuptake inhibitors(SNRI)
S/E:nausea,GI upset,agitation,insomnia,sexual dysfunction,hypertension.Is useful in treatment of
refractory depression.
Mirtazapine : is noradrenergic and specific serotonergic antidepressant(NaSSA)
Side effects;include sedation, weight gain, dizziness, somnolence.
Reboxetine:Is noradrenline reuptake inhibitor(NARIs)
S/E:Insomnia,sweating,postural hypotension, sexual dysfunction, urinary retention,dysuria.
 Antipsychotics: used in combination with antidepressant medications in the treatment of
depression with psychotic features (psychotic depression).
 Psychotherapy
Several trials of combination of pharmacotherapy with psychotherapy for chronically depressed
patient have shown a higher response rate and higher remission rate for the combination than for
either treatment used alone.
1.Cognitive behavioral therapy:
2.Interpersonal therapy
3.Family therapy
4.Supportive therapy
 Electroconvulsive therapy(ECT)
Cerletti and Bini introduced the use of 'electric shock' to induce seizures in1938, and soon this
method became the standard.
Initially ECT was 'unmodified'(i.e. without anesthesia) ,but because of frequent injury, the current
procedure is' modified'.
Mode of action
The exact mechanism is unknown but it is thought to be complex including neurotransmitter
release, hormone secretion from the hypothalamus and pituitary, modulation of neuroreceptors,
changes in blood–brain barrier permeability.
o The induction of generalized seizure is necessary for both the beneficial and the adverse
effects of ECT.
o The patient is anaesthetized and given a muscle relaxant; seizures are then induced by
delivering brief electrical stimuli to the brain via scalp electrodes.
o The duration of seizure is between 20 and 50 seconds.
o Patients usually receive a total of 4–12 treatments, given twice weekly.
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Special Preparation for ECT:
1) Ensure full medical history and current medication noted on ECT recording sheet.
2) Complete physical examination.
3) Ensure recent routine blood tests done(blood suger,urea,other blood tests)
4) If indicated, arrange pre-ECT chest x-ray, and ECG.
5) Ensure consent from has been signed.
6) Check patient's identity pre-ECT.
7) Check patient is fasted (8hrs) and has emptied their bowels and bladder prior coming to
ECT room.
8) Check patient is not wearing jewellery/dentures have been removed.
9) Check no medication that might increase or reduce seizure threshold has been recently
given .e.g., most antipsychotic and antidepressants lower seizure threshold, whilst
Benzodiazepine ,carbamazepine and Valproate increase the threshold.
10) Ensure that grease and hair lacquer are removed by ward staff before the patient sent for
ECT.
11) Check ECT machine is functioning correctly.
Electrode placement
Bilateral ECT; electrodes are placed on opposite sides of the head, each 3cm above the
midpoint of the line joining the external angle of the orbit to the external auditory meatus.
Unilateral ECT; the first electrode is placed on the non-dominant side, 3 cm above the
midpoint between the external angle of the orbit and the external auditory meatus. The second
is at least 10 cm away from first, vertically above the meatus of the same side.
Unwanted effects of ECT
Early some loss of short term memory; retrograde amnesia-usually resolves completely.
Headache
Temporary confusion
Muscular aches
Occasional damage to the teeth,tongue,or lips and fracture may occur.
Electrical burns.
Mortality; no greater than for general anesthesia in minor surgery, is 2-3/100000,usually due
to cardiac complications.
Contraindications of ECT
There are no absolute contraindications. Use of ECT should be limited for patients with
serious anesthetic risk, recent MI, Cardiac arrhythmias, cerebral aneurysm, raised intracranial
pressure.
Indication for ECT
1)Major depression; indications of ECT in depression;-Not responding to antidepressant drugs
-With psychotic features
-With failure to eat and drink
-With depressive stupor
-With high suicidal risk
2) Mania not responding to drug treatment
3) Other uses apart from mood disorders are Post partum psychosis, catatonic
schizophrenia and schizoaffective depression.
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Resistant Depression: is defined as a depressive disorder does not respond within a
reasonable time to a chosen combination of antidepressant drugs and psychological treatment.
Treatment of resistant depression
 Review diagnosis: is diagnosis correct? Are there any undressed maintaining factors(e.g.
social,
physical, psychological).
 Ensure compliance by means of blood sampling and methods of giving the medications.
 Increase the dose of the current antidepressant to a maximum dose.
 Add another antidepressant
 Consider change of antidepressant; try a different class of antidepressant.
 Consider augmentation with:
- mood stabilizers (lithium, carbamazepine)or
- add quetiapine ,Resperidone or Aripiprazole
-combine fluoxetine with olanzapine
-Addition of tri-iodothyronine.
 Consider ECT if all treatment failed or there is life threatening situation.
Bipolar affective disorder
o Bipolar I:The occurrence of one or more manic episodes or mixed episodes with or with out a
history of one or more depressive episodes.
o BipolarII : The occurrence of one or more depressive episodes accompanied by at least one
hypomanic episode.
 Mania: Mood state characterized by elation, agitation, hyperactivity, hyper sexuality, and
accelerated thinking and speaking, and may be accompanied with psychotic features. The least
duration to diagnose manic episode is 1 week. Manic episode also divided into mild, moderate, severe
without psychosis, and severe with psychosis.
 Hypomania: mood abnormality with the qualitative characteristics of mania but somewhat less
intense and without psychosis. The least duration to diagnose hypomania is 4 days
Epidemiology
o The life time risk of bipolar disorder lies between 0.3-1.5%.
o The prevalence in male and female is equal.
o The mean age of onset is about 21 years of age.
o Bipolar disorder is highly co-morbid with other disorders (anxiety disorder, substance misuse).
Etiology
 The predisposition to develop mania has an important genetic contribution, the concordance
rate of mood disorder in the monozygotic co-twin of a proband with bipolar disorder is
between 60-70% , but of dizygotic twins the rate is only about 20%.
 Neurotransmitters: NA.5HT,Dopamine and glutamine have all been implicated .
Clinical features of Mania
o Mood: Elevated and expansive mood , feels full of energy, vitality and considers himself very
healthy or may have irritable mood.
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o Behavior: Over activity ,restlessness, agitation, disinhibited(loss of the normal sense of which
behaviours are appropriate in the current social setting), spending a lot of money on themselves
and on people and may be violent.
o Thoughts:
Flight of ideas; in which thoughts running fast and concepts and subjects run fast and jumping
from one topic to another by distracting cues in the environment or sound association (Clang
association) or topics are connected by similarities in the meaning of the words used (Puns
association).
Delusions secondary to the mood state can develop e.g. Grandious delusions, Religious delusions
and even paranoid delusion.
o Speech: Pressure of speech{the speech is rapid,difficult to interrupt}.
o Perception: second person auditory hallucination can occur in mania and are mood congruent
"e.g. telling him you are so important
o Cognitive: Poor concentration and memory
o Insight: the insight is impaired in mania.
o Appearance
The patient's appearance often reflects his prevailing mood.
Clothes may be brightly colored
When the condition is more sever, the patient's appearance is often untidy and disheveled.
DSM-IV Diagnositic criteria of Manic Episode:
(A) Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at
least 1 week.
(B) During the period of mood disturbance three (or more) of the following symptoms have
persisted (four if the mood is only irritable) and have been present to a certain degree.
1-Inflated self-esteem or grandiosity.
2-Decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
3-More talkative than usual or pressure to keep talking
4-Flight of ideas or subjective experience that thoughts are racing.
5-Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli)
6-Increase in goal-directed activity (either socially, at work or school, or sexually) psychomotor
agitation.
7-Excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g. sexual activities without thinking about the effect it may cause, or foolish business investments).
(C) The symptoms do not meet criteria for a mixed episode (depression and mania at the same
time)
(D) Marked socioccuptional impairment.
(E))Exclude mood disorder due to general medical condition (e.g., hyperthyroidism) or substance
induced
Course and prognosis:
 The average length of a manic episode is about 6 months, and about 90% of manic patients
experience further episodes of mood disturbance and an average of 10 mood episodes within
25 years.
 If 4 episodes of mood swings / 1 year then it is regarded as Rapid cycling mood disorder.
 The interval between episodes becomes progressively shorter with both age and the number of
episodes.
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Morbidity /Mortality
Mortality and morbidity rates are high, in terms of lost work, lost productivity, effects on
marriage and the family. Also it's estimated that 15% of people with bipolar disorder take their
own life. Bipolar affective disorder highly co morbid with drug/alcohol misuse and anxiety.
Differential diagnosis
Depending upon the nature of the presenting episode.
1-Schizophrenia
2-Organic brain disorder involving the frontal lobes (including brain tumor and HIV infection)
3-States of brief excitement induced by amphetamine and other illicit drugs.
Management of Bipolar Disorder
This will depend upon the nature of the presenting episode:
●Treatment of acute manic episode
●Treatment of depressive illness
The pharmacological treatment divided into both acute and maintenance phases.
●Treatment of Acute Mania;
Agents can be used alone or in combination to bring the patient down from a high.
Patients with sever mania are best treated in hospital.
 Acute drug treatment:
 Mood stabilizers: include Lithium and a number of anticonvulsant drugs including
Carbamazepine,sodium valproate. More recently introduced anticonvulsants such as Lamotrigine and
Gabapentine are also being explored for their mood stabilizing effect.
The following mood stabilizers can be used for acute treatment of mania:
 Lithium:
Is effective for the acute treatment of mania, also can be used for the prophylaxis of bipolar
disorders. It is not so effective against severe depression with psychotic features nor with rapid
cycling.
Mode of action; uncertain, numerous effects on biological system. it can substitute for Na, K, Ca,
Mg and may have effects on cell membrane electrophysiology and the release of
neurotransmitters and second messenger system.
Blood levels correlate with clinical efficacy. The major drawback of lithium is its high
Incidence of side effects and very narrow therapeutic index:
� Therapeutic range: 0.7 to 1.2 mmol/L(Individual patients can become toxic even within
this range.)
� Toxic: > 1.5
� Lethal: > 2.0.
Side Effects:
Side effects of lithium include fine tremor, sedation, ataxia, thirst, metallic taste, polyuria,
edema, weight gain, hair loss, GI problems, reversible ECG changes ,benign leukocytosis, thyroid
enlargement, hypothyroidism, and nephrogenic diabetes insipidus.
Toxic levels of lithium cause altered mental status, coarse tremors, convulsions,and death.
If theses symptoms appear, lithium must be stopped at once and a high intake of fluid provided,
with extra sodium chloride to stimulate an osmotic diuresis. In sever cases, renal dialysis may be
needed.
Clinicians need to regularly monitor blood levels of lithium every 6-12 weeks, and every 6 month,
blood samples should be taken for electrolytes, blood urea,creatinin, thyroid function and a full
blood count.
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Valproate(Depaken):Is effective in the acute management of mania and it is more effective than
lithium in rapid-cycling disorder.
Its mechanism of action is unknown, but it has been shown to increase central nervous system
(CNS) levels of gamma-aminobutyric acid(GABA).
Dose; can be started at a dose of 400-600 mg daily, which may be increased to a range of 1-2
gm/daily.
Side effects:
Side effects include sedation, weight gain, GIT upset, alopecia, hemorrhagic pancreatitis,
hepatotoxicity, and thrombocytopenia. It has teratogenic effects during pregnancy
(neural tube defects).
Monitoring of Liver function test and complete blood count is necessary.
Carbamazepine:is effective in the management of acute mania, it has also some benefit in the
treatment of drug-resistant bipolar depression.
It acts by blocking sodium channels and inhibiting action potentials.
Dose; starting as 400-600 mg/ daily in divided dose and can be increased up to 800-1200 mg/day.
Side effects:
Side effects include skin rash, drowsiness, ataxia, slurred speech, leucopenia,
hyponatremia, aplastic anemia, and agranulocytosis. It elevates liver enzymes and has
teratogenic effects when used during pregnancy (neural tube defects).
Pretreatment complete blood count (CBC) and LFTs must be obtained and monitored regularly.
 Antipsychotics
 Atypical antipsychotic: Olanzapine,Risperidone,Quetiapine and Aripiprazole are licensed for the
treatment of mania .
 Clozapine can be of value in patients with intractable manic symptoms
 Typical antipsychotics have long been used in mania but the observation that may induce depression
and tardive dyskinesia militates against their long term use.
 Benzodiazepines: e.g. Lorazepam can be used in combination with the mood stabilizers or the
antipsychotic drugs to reduce the agitation.
 Psychotherapy: Cognitive therapy may help some patients accept their illness and the need for
medical treatment and explanation about the risk of recurrence.
 Electroconvulsive therapy: can be used if;
 Medication failed
 If life threatening conditions e.g. extreme over activity or physical exhaustion.
It can give 80% rate of rapid improvement.
Continuation of treatment: some form of continuation treatment is advisable for at least 6 months;
treatment should not be withdrawn finally until patients have been asymptomatic for at least 8
weeks.
Treatment of depressive episode(Bipolar depression)
Depressive episodes are common in bipolar illness; treatment of depression in the context of bipolar
disorder can be problematic because standard antidepressant treatment carries risk of inducing mania.
The following are some lines for treating bipolar depression:* Lithium: is a useful antidepressant in bipolar patients.
*Lithium in combination with Antidepressant
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*Lamotrigine
*Choice of antidepressant:-recent studies have suggested that the (SSRI) may be better tolerated,
work more quickly, and have a lower associated risk of inducing mania or rapid cycling
compared to tricyclic antidepressants .
*If severely depressed, suicidal, or where urgent treatment necessary ,consider ECT.
Prophylaxis
Primary aim is for Prevention of recurrent episodes(either mania or depression)
Indications:Any patient has had at least 2 episodes in 5 years
First –line treatment:Lithium
Second line treatments:Carbamazepine,Sodium valproate,Lamotrigine,topiramate
.
References
1)Gelder M, Harrison P, Cowen P. Shorter Oxford Textbook of Psychiatry, Fifth Edition. Oxford
University Press, Oxford. 2006.
2)Johnstone E, Owens D, Lawrie S, Sharpe M, Freeman C. Companion to Psychiatric Studies,
Seventh Edition. Churchill Livingstone, Edinburg. 2004.
3)Sadock B, and Sadock V. Kaplan and Sadock‟s Synopsis of Psychiatry, Behavioral
Sciences/Clinical Psychiatry, Ninth Edition. Lippincot Williams and Wilkins, Philadilphia. 2003.
4)Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines, Tenth Edition. Informa
Healthcare, London. 2010
5)American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000
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