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Mood disorders
Dr.Saman Anwar Faraj
M.B.Ch.B, F.I.B.M.S(PSYCHIATRY)
Mood Disorder
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Mood change is the main psycho pathological
feature.
The abnormality is more intense and persistent
than normal variation in mood and often lead to
problems in occupational and social functioning.
Mood disorder
mood disorder is the term given for a group of
diagnoses in the DSM IV TR disorders in ICD 10.
 English psychiatrist Henry Maudsley proposed an
overarching category of affective disorder. The term was
then replaced by mood disorder, as the latter term refers
to the underlying or longitudinal emotional state,
whereas the former refers to the external expression
observed by others.
 Two groups of mood disorders are broadly recognized;
the division is based on whether the person has ever
had a manic or hypomanic episode. Thus, there are
depressive disorders, of which the best known and most
researched is major depressive disorder commonly called
clinical depression or major depression, and bipolar
disorder, formerly known as "manic depressive" and
described by intermittent periods of manic and
depressed episodes.
Classification of mood disorders
DSM-IV-TR describes the following
episodes:
1-Major Depressive Episode: lasts for 2 weeks
2-Manic Episode: one week
3-Hypomanic Episode: four days
4-Mixed Episode: one week
Classification of Mood Disorders
cont’d
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Major Depressive Disorder
Bipolar I Disorder= having a clinical course of
one or more manic episodes and, sometimes,
major depressive episodes.
Bipolar II Disorder: episodes of major
depression and hypomania
Dysthymic Disorder : 2years
Cyclothymiacs Disorder
Epidemiology of mood disorders;
 19.3% of the general population develops a
mood disorder (14.7% men, 23.9% women)
 21.3% of women & 12.7%of men develop major
depression.
 Average age of onset for bipolar illness is mid to
late twenties.
 Average age of onset of depression is mid
thirties.
 Bipolar disorder occurs more in high
socioeconomic groups.
 Mania and depression are manifested by
symptoms involving the effective, cognitive,
Physical, social, and spiritual aspects of the
individual.
Major depressive disorder
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Common disorder, with a lifetime prevalence of about
15% ,perhaps as high as 25% in women.
The incidence of major depressive disorder is also
high in primary care patients ,in whom it approaches
10%, and in medical inpatients , in whom it
approaches 15%.
An almost universal observation , is the two-fold
greater prevalence of the disorder in women than in
men.
The reasons for this difference have been
hypothesized to involve hormonal differences, the
effect of childbirth, and differing psychosocial stresses
for women and for men.
Major depressive disorder
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The mean age of onset is about 40 years ; 50% of all patients
have an onset between age of 20-50 .
Although uncommonly, MDD can also begin in childhood or in old
age.
Some recent studies suggest that the incidence of MDD may be
increasing among people less than 20 years old.
MDD occurs most often in people without close interpersonal
relationships or in those who are divorced or separated .
No correlation have been found between socio-economic status
and MDD
Etiology

1.
2.
Although the etiology of MDD is ambiguous and complex, it can be
divided into three main groups: biological ,genetic ,and
psychosocial.
Biological factors:
a. Biogenic amines :norepinephrine , and serotonin are the most
implicated.
b. Other neuro-chemical factors: GABA ,and neuroactive peptides
particularly vasopressin, and the endogenous opiates.
c. Neuro-endocrine regulation :adrenal , thyroid and growth
hormone.
d. brain imaging abnormalities: still inconclusive.
Genetic factors :
genetic data strongly indicate that significant genetic factor is
involved in the development of mood disorders. First degree
relatives of MDD are 1.5-2.5 times more likely to have bipolar I
disorder, and 2-3 times to have MDD. The concordance rate for MZ
twins is about 50% while in DZ twins is 10-25%.
3. Psychosocial factors :
a- life events and environmental stress:
The life event most often associated with a
person later development of depression is losing
a parent before the age of 11. The
environmental stressor most often associated
with the onset of an episode is the loss of a
spouse.
b- Family.
c- premorbid personality factors.
d- learned helplessness.
e- cognitive theory.
Signs and symptoms
Two hallmarks of depression symptoms
key to establishing a diagnosis are:
1. Loss of interest in normal daily
activities You lose interest in or
pleasure from activities that you used
to enjoy.
2.
Depressed mood. You feel sad,
helpless or hopeless, and may have
crying spells.
Signs and Symptoms Cont’d
3. Sleep disturbances
 Insomnia or Sleeping too much
Waking in the middle of the night or
early in the morning and not being able
to get back to sleep.
4. Impaired thinking or concentration
 Trouble concentrating or making
decisions.
 Problems with memory.( difficulty with
short term memory).
Signs and Symptoms Cont’d
5. Changes in weight
 An increased or reduced
6. Fatigue or slowing of body
movements.
 lack of energy.
 Feel as tired in the morning.
 Have trouble getting out of bed.
 Feel like you're doing everything in
slow motion, or you may speak in a
slow, monotonous tone.
Signs and Symptoms Cont’d
7. Low self-esteem
 Feel worthless.
 Excessive guilt.
 Pessimism, poor self-esteem.
 Self-criticism
8. Agitation
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You may seem restless, agitated,
irritable and easily annoyed.
Difficulty controlling your temper.
Signs and Symptoms Cont’d
9. Physical complaints, such as
gastrointestinal problems (indigestion,
constipation or diarrhea), headache and
backache. Many people with depression
also have symptoms of anxiety.
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Children, teens may react differently to
depression.
Kids may pretend to be sick, worry that a
parent is going to die, perform poorly in
school, refuse to go to school, or exhibit
behavioral problems.
Signs and Symptoms Cont’d
10. Less interest in sex.
11. Thoughts of death.
 A persistent negative view of
yourself, your situation and the
future. thoughts of death, dying or
suicide.
Differential diagnosis
1.Medical disorders:
Endocrine disorders, infections, metabolic disorders ,
nutritional deficiencies, connective tissue diseases , drugs
(steroids , contraceptive pills, analgesics,..),……etc.
2. Neurological disorders: brain tumors, infections, head injury ,
epilepsy ,etc.
3. Mental disorders: anxiety disorders, bipolar disorder,
schizoaffective disorder, schizophrenia, substance abuse,
Dementias and pseudodementia
4. Uncomplicated bereavement.

Depressive disorders
Diagnosticians recognize several subtypes or course
specifiers:
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Atypical depression is characterized by mood reactivity
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(paradoxical anhedonia) and positivity, significant weight
gain or increased appetite ("comfort eating"), excessive
sleep or somnolence (hypersomnia), a sensation of
heaviness in limbs known as leaden paralysis, and
significant social impairment as a consequence of
hypersensitivity to perceived interpersonal rejection.

Psychotic depression is the term for a major depressive
episode, particularly of melancholic nature, where the
patient experiences psychotic symptoms such as
delusions or, less commonly, hallucinations. These are
most commonly mood-congruent (content coincident
with depressive themes).
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Catatonic depression is a rare and severe form
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Postpartum depression is listed as a course
of major depression involving disturbances of
motor behavior and other symptoms. Here the
person is mute and almost stuporose, and either
immobile or exhibits purposeless or even bizarre
movements. Catatonic symptoms also occur in
schizophrenia, a manic episode, or be due to
neuroleptic malignant syndrome.
specifier in DSM-IV-TR; it refers to the intense,
sustained and sometimes disabling depression
experienced by women after giving birth.
Postpartum depression, which has incidence rate
of 10–15%, typically sets in within three months
of labour, and lasts as long as three months
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Seasonal affective disorder is a specifier. Some people
have a seasonal pattern, with depressive episodes
coming on in the autumn or winter, and resolving in
spring. The diagnosis is made if at least two episodes
have occurred in colder months with none at other times
over a two-year period or longer.
Dysthymia, which is a chronic, milder mood
disturbance where a person reports a low mood almost
daily over a span of at least two years. The symptoms
are not as severe as those for major depression,
although people with dysthymia are vulnerable to
secondary episodes of major depression (sometimes
referred to as double depression).
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Recurrent brief depression (RBD), distinguished
from Major Depressive Disorder primarily by
differences in duration. People with RBD have
depressive episodes about once per month, with
individual episodes lasting less than two weeks
and typically less than 2–3 days. Diagnosis of
RBD requires that the episodes occur over the
span of at least one year and, in female
patients, independently of the menstrual cycle.
People with clinical depression can develop RBD,
and vice versa, and both illnesses have similar
risks.
Minor depression, which refers to a depression
that does not meet full criteria for major
depression but in which at least two symptoms
are present for two weeks.
Treatment
Treatment have those galls:
Risk Assessment
Ensure the safety of the patients
Ensure complete diagnostic evaluation
Ensure treatment of the immediate
symptoms and the future of the patients.
Hospitalization:
For diagnostic evaluation, suicide and
homicide risk, dehydration and starvation,
loss of social support.
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It is necessary that every patient, whom we
suspect to have mood disorders, should be
thoroughly assessed by careful and full history
and mental state examination. The notes of
the social worker and clinical psychologists
should be studied too. The necessary
investigations to exclude other possible
causes should be done including full blood
count, drug screening , hormonal essays
including thyroid function tests, EEG, CT scan
and if necessary other neuroimaging
techniques.
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The line of management depends on whether
the disorder is acute or chronic, bipolar
unipolar, recurrent or a single episode.
The choice of the treatment method should
be made by discussion with the patient, his
relatives and individual physician.
The treatment methods include:
Psychological
Pharmacological
Physical
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Treatment
Psychosocial Therapy:
Cognitive therapy: was developed originally by Aaron Beck.
Focuses on cognitive distortions postulated to be present
in MDD. It works by helping patients identify and test
negative cognitions; develop alternative, flexible, and
positive ways of thinking; and rehearse new cognitive
and behavioural responses.
Interpersonal therapy: was developed by Gerald Klerman,
focuses on one or two of the patient’s current
interpersonal problems. It is based on two assumptions.
First, current interpersonal problems are likely to have
their roots in early dysfunctional relationships.
Personality factors need to be addressed and does not
deal with dynamics of the patient’s problems.
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Treatment
Psychosocial Therapy:cont
Behaviour Therapy: is based on the hypothesis that
maladaptive behavioural patterns result in a person’s
receiving little positive feedback and perhaps outright
rejection from society.
Psychoanalytically Oriented Therapy: the aims include
improvement in interpersonal trust, intimacy, coping
mechanisms, the capacity to grieve and the ability to
experience a wide range of emotions.
Family Therapy: is indicated if the disorder jeopardizes a
patient’s marriage or family functioning or if the mood
disorder is promoted or maintained by the family
situation
Treatment
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Pharmacotherapy:
All current available antidepressants may take up to 3 to 4
weeks to exert significant therapeutic effects.
Patient Education: patient should be educated about the
illness, benefit of drugs, side effects. Avoid providing
patients with large prescriptions due to the risk of
suicide.
Alternatives to drug therapy: ECT is used when a patient is
unresponsive to pharmacotherapy or the clinical situation
is so severe that the rapid improvement seen with ECT is
needed. Occasionally it is treatment of choice such as
older depressed patients. Phototherapy use in seasonal
mood disorder.
Treatment should continue for at leas 6
months after remission.
Prophylactic treatment should be used in
recurrent cases, suicidal ideation and
impaired psychosocial functioning
Augmentation is used when treatment fails:
Lithium, Liothyrnine, L tryptophan.
In mild depression psychotherapy is the
first line treatment and pharmacological
therapy is not recommended routinely as first
line therapy.
In moderate to sever depression when
other treatments for two weeks fail
antidepressants should be first line treatment.
In dysthymia antidepressants could be used
as first line treatment.
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Tricyclic antidepressants:
These drugs have many side effects including
anticholinergic effects, hypotension and
tachycardia and cardiac toxicity which makes
them dangerous in toxicity and overdoses.
Tricyclic antidepressants should not be used
as first line treatment in mild to moderate
depression.
They are recommended for severely ill
inpatients.
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Specific serotonin reuptake inhibitors:
Including fluoxitine, paroxitine, fluvoxamine,
citalopram, sertraline, escitalopram.
They are recommended by NICE as first line
pharmacological treatment of depression
because they have less side effects compared
to tricyclic antidepressants. They are relatively
safer in overdoses. However they might lead
to gastric irritation, nausea, vomiting,
headache, increased anxiety and sexual
dysfunction.
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Specific serotonin reuptake inhibitors:
They cause decreased arousal, drive and
difficulty reaching orgasm. These side effects
might lead to noncompliance.
The initial increased anxiety might lead to
suicide.
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Monoamine oxidase inhibitors MAOIs :
They are used for atypical depression with
reversed biological symptoms as increased
appetite and weight. It is recommended by
NICE for those who do not respond to SSRIs.
The ireversible MAOIs have serious
interaction with drugs and food containing
tyramine.
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Monoamine oxidase inhibitors MAOIs :
The reversible MAOIs as Meclobemide has
less risk of interaction but therapeutically less
effective.
Those drugs lead to postural hypotension ,
overstimulation, sexual dysfunction, weight
gain and possibly addiction.
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Serotonin and noradrenaline reuptake
inhibitors SNRIs:
Venlafaxine and duloxetene.
Venlafaxine is more potent than SSRIs and
recommended by NICE for severely
depressed patients with monitoring the blood
pressure.
Doluxetene is not as potent as Venlafaxine
and it might lead to initial nausea.
Both drugs lead to nausea, hypertension,
increased anxiety and sexual dysfunction.
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Other antidepressants:
reboxetene: is selective noradrenaline
reuptake inhibitor. It has
anticholinergic side effects and sexual
dysfunction. Neverthelss it is well
tolerated but evidence of its
effectiveness is scarce.
mirtazepine: is α 2 adrenoceptor
antagonist. It cause sedation and
weight gain. Therefore it liked by
patients with insomnia and disliked by
obese patients.
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Other antidepressants:
Mianserine is a tetracyclic drug and is
α2 adrenoceptor antagonist. It is less
popular now because of
agranulocytosis.
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Treatment resistant depression:
Augmetation therapy:
Antidep and psychtherapy
Antidep and atypical antipsychotic
Antidep and thyroid hormone
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Mania
Defination
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Mania is a Greek word mean
madness.
The term used to describe a
syndrome involving sustained and
pathological elevation of mood
accompanied by other changes such
as disturbances of physical energy ,
sleep and appetite with psychotic
features.
Definition.. Cont’d
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Bipolar Affective Disorder (BAD)
is an episodic illness , where periods
of normal psychological functioning
are interrupted at intervals by
periods of either mania or
depression.
Definition.. Cont’d
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Bipolar 1 disorder previously called
Manic Depressive Illness
characterizes with episode of mania
and depression or mania only.
Bipolar 2 disorder characterized with
depression and few hypomania
episode.
Features of a Manic Episode
1. Emotional symptoms
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Extreme irritability & distractibility
.
Excessive "high" or euphoric
feelings.
Emotional liability between anger
and euphoria.
Features of a Manic Episode
2. Cognitive symptoms
 Inflated self esteem and grandiosity.
 Reported self confident, capable and
can do things better than other.
 Unrealistic belief in one's own
abilities and achievement
 Delusion of grandeur that they are
famous, gift, and extraordinary.
 Thought flow, flight of idea
 Poor judgment regarding personal,
social, occupation and activities.
Features of a Manic Episode
3. Behavioral symptoms
 Increased talkativeness, agitation,
excessive involvement in
pleasurable activities.
 Wearing bright color, unusual dress &
heavy makeup.
 Productivity, creative involves in
project with negatives consequences.
 Decreased sleep, Increased sex drive
 Substance abuse.
 Provocative or noxious behavior
 Denial of problem.
Hypomania
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Is somewhat similar to mania, a less
extreme mood state, hypomania is
defined as an elevated mood during
which (1) no hospitalization has ever
been necessary and (2) no state of
delusional or other psychotic
thinking ever coincided with the
elevated mood.
Hypomania are not sever enough to

Hypomania may feel good to the person who
experiences it. Thus, even when family and
friends learn to recognize the mood swings, the
individual often will deny that anything is wrong
Mixed affective episode
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In the context of bipolar disorder, a mixed state
is a condition during which symptoms of mania
and clinical depression occur simultaneously.
Treatment
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1. Medications
A. Mood stabilizer is the first line of
treatment for manic episodes. E.g.
Lithium
Mood regulators Anti-seizure
medications, such as valproic acid
(Depakene),and lamotrigine
(Lamictal).
Antipsychotic medications such as
risperidone (Risperdal), olanzapine
(Zyprexa) or Seroquel.
Treatment….Cont’d
Mood Stabilize
Adverse Effects Special Concerns
Lithium carbonate
Gastrointestinal
(Eskalith CR, Lithobid) distress, lethargy or
sedation, tremor,
Hypothyroidism,
diabetes insipidus,
renal disease
valproic acid
(Depakote, Depakene
Sedation, platelet
dysfunction, liver
disease, alopecia,
weight gain
Elevated liver enzymes
or liver disease, drugdrug interactions, bone
marrow suppression
Carbamazepine
(Tegretol)
Suppressed WBC,
dizziness, drowsiness,
rashes, liver toxicity
(rarely)
Drug-drug interactions,
bone marrow
suppression
Treatments
3. Electroconvulsive therapy (ECT)
ECT may also be considered to treat
acute episodes when medical
conditions, including pregnancy,
make the use of medications too
risky. ECT is a highly effective
treatment for severe depressive,
manic, and/or mixed episodes.
Thank you