Download Mood Disorders: Introduction and Overview

Mood Disorders (Affective disorders)
A group of psychiatric disorders in which pathological moods and related
vegetative and psychomotor disturbances dominate the clinical picture.
It refers to sustained emotional states, not merely to the external
(affective) expression of the present emotional state, sustained over a
period of weeks to months, often in periodic or cyclical fashion.
Depressive disorders afflict at least 20 percent of women and 12 percent
of men at some time during their lives. Despite the availability of
effective treatments, many persons with mood disorders are disabled, and
rates of suicide (which occurs in about 15 percent of depressive
disorders) are high in both young and (especially) elderly men. Although
depressive disorders are more common in women, more men than women
die of suicide.
Major Depressive Disorder and Bipolar Disorder:
Major depressive disorder (unipolar depression) is reported to be the
most common mood disorder. It may manifest as a single episode or as
recurrent episodes. The course may be up to 2 years or longer—in those
with the single-episode form. Whereas the prognosis for recovery from an
acute episode is good for most patients with major depressive disorder,
three out of four patients experience recurrences throughout life.
Bipolar disorders (previously called manic-depressive psychosis) consist
of at least one hypomanic, manic, or mixed episode. Mixed episodes
represent a simultaneous mixture of depressive and manic or hypomanic
manifestations. Although a minority of patients experience only manic
episodes, most bipolar disorder patients experience episodes of both
polarity. Manias predominate in men, depression and mixed states in
women.
Recent clinical studies have shown the existence of a spectrum of
ambulatory depressive states that alternate with milder, short-lived
periods of hypomania rather than full-blown mania (bipolar II disorder).
Mood Disorders
Major depressive disorder: characterized by one or more major
depressive episodes (at least 2 weeks of depressed mood or loss of
interest accompanied by at least four additional symptoms of depression,
see later).
Dysthymic disorder: characterized by at least 2 years of depressed
mood for more days than not, accompanied by additional depressive
symptoms that do not meet criteria for major depressive episode.
Bipolar I disorder: characterized by one or more manic or mixed
episodes, usually accompanied by major depressive episodes.
Bipolar II disorder: characterized by one or more major depressive
episodes accompanied by at least one hypomanic episode.
Cyclothymic disorder: characterized by at least 2 years of numerous
periods of hypomanic symptoms that do not meet criteria for a manic
episode, and numerous periods of depressive symptoms that do not meet
criteria for a major depressive episode.
Mood disorder due to general medical condition: characterized by a
prominent and persistent disturbance in mood that is judged to be a direct
physiological consequence of a general medical condition.
Substance-induced mood disorder: characterized by prominent and
persistent disturbance in mood that is judged to be a direct physiological
consequence of a drug of abuse, toxin exposure, or a medication.
MAJOR DEPRESSIVE DISORDERS
- Clinical features vary in nature and severity from patient to patient.
- The following list of features is not necessarily to be present in all
patients.
A. Mood (Affective) Changes:
B. Appearance & Behaviour:
ness:
- turning downwards of corners of mouth.
- down cast gaze.
- tearful eyes.
- reduced rate of blinking.
- head is inclined forwards.
- lack of motivation and irritation.
- slow movements.
- slow interactions.
C. Biological Features (Neurovegetative Signs):
d).
- 3 hours before the usual
time, this is usually associated with severe depression.
ased).
D. Cognitive Functions & Thinking:
success in life, no longer feels confident, sees himself as failure).
-blame.
wishes ( may progress to suicidal ideation and attempt ).
Psychotic Features Associated with Severe Depression
A. Delusions (mood-congruent)
1. Delusion of guilt (patient believes he deserves severe punishment).
2. Nihilistic delusion (patient believes that some part of his body ceased
to exist or function, e.g. bowel, brain…).
3. Delusion of poverty and impoverishment.
4. Persecutory delusion (patient accepts the supposed persecution as
something he deserves, in contrast to schizophrenic patient).
B. Hallucinations (mood-congruent)
1. Usually second person auditory hallucinations (addressing derogatory
repetitive phrases).
2. Visual hallucinations (scenes of death and destruction) may be
experienced by a few patients.
Epidemiology of Major Depression
).
- 25 %.
- 50 years).
In adolescents may be precipitated by substance abuse.
onfiding relationship (e.g. divorced,
separated, single…).
- economic status and
major depressive disorder.
Etiology of Major Depression:
The causative factors are multifactorial (interacting together)
A-GENETIC FACTORS :as supported by family and twin studies.
B-- BIOLOGICAL FACTORS
Reduced levels of:
C-PSYCHOLOGICAL FACTORS
Differential Diagnosis of Major Depression :
- Thyroid dysfunction. Diabetes mellitus. - Cushing’s disease. - Parkinson’s disease. - Stroke. Carcinoma (especially of the pancreas and lung). - Multiple sclerosis.
- Antihypertensives (resepine, beta-blockers). - Corticosteroids.
- Antineoplastic drugs.
- Bromocriptine.
- Indomethacin.
- L - dopa.
ic).
- induced mood disorder.
DSM-IV Criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed mood or
(2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by
either subjective report. Note: in children and adolescents, can be irritable
mood.
(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 (e.g., a change
of more than 5% of body weight in a month), or decrease or increase in
appetite nearly every day. Note: in children, consider failure to make
expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day .
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day .
(8) diminished ability to think or concentrate, or indecisiveness, nearly
every day .
(9) Recurrent thoughts of death, 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.
C. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by bereavement.
PSYCHOMOTOR RETARDATION
(1) Paucity of spontaneous movements
(2) Slumped posture with downcast gaze
(3 )fatigue
(4) Reduced flow and amplitude of speech
(5) Poor concentration and forgetfulness.
(6) Inability to make simple decisions.
Management of Major Depression:
Treatment of Depression
A Strategic map for managing mood disorders,
(1) Symptom remission (acute phase) and restoration of psychosocial
functioning (acute and continuation phases).
(2) Prevention of a relapse (continuation phase).
(3) Prevention of recurrences, or new episodes in patients with recurrent
depressions (maintenance phase).
drinking (for ECT).
de
-Antidepressants.
-Tricyclics / Tetracyclics .
- Monoamino oxidase inhibitors (MAOI) .
-Selective serotonin reuptake inhibitors (SSRIs) .
-Others (new agents)
- Desirable therapeutic antidepressant effect requires a period of time,
usually 3-6 weeks. (Side effects may appear within the first few days.)
- After a first episode of a unipolar major depression, treatment should be
continued for six months after clinical recovery, to reduce the rate of
relapse.
- If the patient has had two or more episodes, treatment should be
prolonged for at least a year after clinical recovery to reduce the risk of
relapse.
- Lithium Carbonate can be used as prophylaxis.
Treatment of Depression
A- Psychotherapy:
- Supportive therapy.
- Family therapy.
- Cognitive-behavior therapy (for less severe cases or after
improvement with medication).
B- ELECTROCONVULSIVE THERAPY(ECT):
The effect of ECT is best in severe depression especially with marked
biological (neurovegetative) and psychotic features. . It is mainly the
speed of action that distinguishes ECT from antidepressant drug
treatment. Despite many of the largely societal criticisms of the modern
use of ECT, this modality should be given a higher priority when treating
patients with extreme suicidality, associated medical illnesses, difficult
adverse reactions to routine psychopharmacological agents, or other
medical emergency situations (such as catatonia) that demand the most
rapid treatment response available.
ECT is effective, even in patients who have failed to respond to one or
more medications or combined treatment. It is effective in both psychotic
and nonpsychotic forms of depression. Usually, 8 to 12 treatments are
needed.
C- Light therapy has been most clearly evaluated in mood disorder
with seasonal pattern, either as monotherapy or in combination
with medication. Patients who respond do so within 2 to 4 weeks.
D-Antidepressant Medications;
1-Tricyclic anti depressant:
a-Amitriptyline (Tryptizol) 75–250mg/day
side effect: Sedative
,increase appetite ,Drowsiness, Orthostatic hypotension, Cardiac
arrhythmia, weight gain, anticholinergic effect (Dry mouth, blurred
vision, urinary hesitancy, constipation.), Overdose may be fatal.
b- Clomipramine (Anafranil): dose 75–250 mg Drowsiness, weight
gain.
c- Imipramine (Tofranil) 75–250 mg, Sedative ,increase appetite
Drowsiness, Orthostatic hypotension, Cardiac arrhythmia, weight
gain, anticholinergic effect (Dry mouth, blurred vision, urinary
hesitancy, constipation.), Overdose may be fatal.
2-Tetracyclic anti depressant:
Maprotiline (Ludiomil):75–225mg; Drowsiness, weight gain, lower
than tricyclics anticholinergic effect (Dry mouth, blurred vision,
urinary hesitancy, constipation.), Overdose may be fatal.
3-Mono Amine Oxidize Inhibitor (MAOI):
Irreversible
- Reversible
MAOI have serious side effect with High Tyramine Content Diet and
when combined with other anti depressant (Hypertensive crises).
4-SelectivSerotinine Reuptake Inhibitor(SSRI):
a- Fluoxetine (Prozac) 20–80mg
b- Paroxetine (Paxil ,Seroxat) 10–60mg
c- Sertraline (Zoloft) 50–200 mg
d- Fluvoxamine ( Faverin ) 50-300mg
* All SSRIs may cause agitation, sedation, GI distress, sexual
dysfunction
5- Other antidepressants:
Mirtazapine ( Remeron )
Prognosis of Unipolar Depressive Disorders
- About 25 % of patients have a recurrence within a year.
- Ten percent will eventually develop a manic episode.
- A group of patients have chronic course with residual symptoms and
significant social handicap.
DSM-IV Diagnostic Criteria for Dysthymic Disorder
A. Depressed mood for most of the day, for more days than not, for at
least 2 years. Note: In children and adolescents, mood can be irritable and
duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
(1) poor appetite or overeating
(2) insomnia or hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty making decisions
(6) feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the
disturbance, the person has never been without the symptoms in criteria A
and B for more than 2 months at a time.
D. No major depressive episode has been present during the first 2 years
of the disturbance (1 year for children and adolescents).
In addition, after the initial 2 years (1 year in children or adolescents) of
dysthymic disorder, there may be superimposed episodes of major
depressive disorder, in which case both diagnoses may be given when the
criteria are met for a major depressive episode (Double depression).
E. There has never been a manic episode, a mixed episode, or a
hypomanic episode, and criteria have never been met for cyclothymic
disorder.
F. The disturbance does not occur exclusively during the course of a
chronic psychotic disorder, such as schizophrenia or delusional disorder.
G. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
DSM-IV Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting at least 1 week (or any duration if
hospitalization is necessary).
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 significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for 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) or psychomotor agitation
(7) Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance is sufficiently severe to cause marked
impairment in occupational functioning or in usual social activities or
relationships with others, or to necessitate hospitalization to prevent harm
to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism).
Note: Manic-like episodes that are caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive therapy, light therapy)
should not count toward a diagnosis of bipolar I disorder.
DSM-IV Criteria for Hypomanic Episode
A. A distinct period of persistently elevated, expansive, or irritable mood,
lasting throughout 4 days, that is clearly different from the usual non
depressed mood.
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 significant 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
(6) Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation
(7) Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., the person engages in
unrestrained buying sprees, sexual indiscretions, or foolish business
investments)
C. The episode is associated with an unequivocal change in functioning
that is uncharacteristic of the person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable
by others.
E. The episode is not severe enough to cause marked impairment in social
or occupational functioning, or to necessitate hospitalization, and there
are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism).
Note: Hypomanic-like episodes that are clearly precipitated by somatic
antidepressant treatment (e.g., medication, electroconvulsive therapy,
light therapy) should not count toward a diagnosis of bipolar II disorder.
DSM-IV Diagnostic Criteria for Cyclothymic Disorder
A. For at least 2 years, the presence of numerous periods with hypomanic
symptoms and numerous periods with depressive symptoms that do not
meet criteria for a major depressive episode. Note: In children and
adolescents, the duration must be at least 1 year.
B. During the above 2-year period (1 year in children and adolescents),
the person has not been without the symptoms in criterion A for more
than 2 months at a time.
C. No major depressive episode, manic episode, or mixed episode has
been present during the first 2 years of the disturbance.
Note: After the initial 2 years (1 year in children and adolescents) of
cyclothymic disorder, there may be superimposed manic or mixed
episodes (in which case both bipolar I disorder and cyclothymic disorder
may be diagnosed) or major depressive episodes (in which case both
bipolar and cyclothymic disorder may be diagnosed).
E. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Differentiation of Mood disorders
Diagnoses
MDE
Milder
Manic or Hypomania
depression Mixed
episode
MDE
+
Dysthymic disorder --?
Bipolar I disorder
Bipolar II disorder
Cyclothymia
+
-+
---
+
-+
--
--
--
--
+
-+
-+
+
--
+
-+
--?
+
 +most be present to make the diagnoses
 --most be absent to make the diagnoses
 ? most not occur during the first 2 years of the illness
Treatment of Bipolar disorders
Hospitalization is often indicated for the acutely suicidal or dangerous
patient on self or on the others; or patient how show gross
disorganized behavior and may also be considered for the patient with
associated medical problems.
Treatment of mania (Mood stabilizers):
Lithium
Lithium has been the main line of treatment for acute and prophylactic
treatment of mania. In comparative studies with antipsychotic agents,
it yields better overall improvement in most aspects of manic
symptomatology, including psychomotor activity, grandiosity, manic
thought disorder, insomnia, and irritability. However, the onset of
antimanic action with lithium can be rather slow (2week), even with
aggressive dosing. Until recently, this was traditionally accomplished
with the typical neuroleptic drugs, including the phenothiazines, or
butyrophenones such as haloperidol (Haldol).
Lithium doses; should be administered to achieve concentrations in
serum between 0.6 and 1.2 mEq per liter.
High serum level (1.5 mEq per liter) can lead to toxicity: seizures,
confusion, coma and cardiac dysrhythmia. In sever overdose dialyses
is effective.
In bipolar disorders the high likelihood of relapse (50 percent in the
first 5 months following lithium discontinuation and 80 to 90 percent
within the first year and a half) ,and this should be explained to the
patient.
Valproic Acid:
200-3000 mg/day
As effective as lithium in treating bipolar illness, may be more
effective in treating mixed episode while lithium is more effective in
treating traditional mania.
It is also used as prophylactic agent especially in rapid cycling cases.
Carbamazepine:
200-1800 mg/day
effective in acute mania , bipolar depression and as prophylactic
agent.
Because of the rapidly growing evidence for the parallel acute
antimanic efficacy of the mood-stabilizing anticonvulsants
carbamazepine and valproic acid, it is suggested that these alternative
agents be used as initial treatment.
ECT: may be used to treat booth phase of bipolar disorder.
Treatment of Dysthymia and Cyclothymia:
1- Dysthymia:
Traditionally treated with psychotherapy (cognitive and behavioral
therapy). SSRI and MAOI are more effective than the tricyclic
antidepressant.
2- Cyclothymia:
Treated with mood stabilizers and supportive psychotherapy.