Download Depressive Disorders - New York Medical College

Mood Disorders
Bruce Shapiro, M.D.
April 6, 2001
Do psychiatrists have mood swings?
What Determines Mood?
Harlow and Spitz
Gross Anatomy
Neuroimaging
Regionalization questions
Synapse
Intracellular activities
Brain mediated
environment
Mood Disorders
History...
History
 The Bible (King Saul, Job)
 Hippocrates - Humoral theory
 Arateus - Psychological theory
 1800’s - Physical diagnosis
 1900’s - Psychological diagnosis
 1930’s - Somatic interventions
 1940’s - Psychoanalysis
 1950’s - Psychopharmacology
 1980’s - Biological markers
 1990’s - Neuroimaging
 2000’s - Herbals and magnetism ...
Hippocrates
Mood Disorders
Famous Sufferers ...
Abraham Lincoln
Winston Churchill
Churchill's Black Dog
"Black Dog”: Churchill's name for his
depression
Lord Moran: inborn melancholia
Periods of solitude
Periods of high energy
Highly functional
Ernest Hemingway
Suicide - Familial Aspects
A Quote
“In my last severe depression,
I took coca again and a small
dose lifted me to the heights
in a wonderful fashion”
Sigmund Freud
Freud and Mom or Mom and Freud?
Famous Living Bipolars
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Robert Boorstin, writer, special assistant to
President Clinton
Rosemary Clooney, singer
Dick Cavett, writer, media personality
Kitty Dukakis, former First Lady of Massachusetts
Patty Duke (Anna Pearce), actor, writer
Connie Francis, actor, musician
Shecky Greene, comedian
Kristy McNichols, actress
Kate Millett, writer
Charley Pride, musician
Axl Rose, musician
Ted Turner, entrepreneur, media giant
Jonathon Winters, comedian, actor, writer, artist
Famous Living Unipolars
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Buzz Aldrin, astronaut
Rona Barrett, entertainment reporter, author
Art Buchwald, writer
Barbara Bush, former U.S. First Lady
Ray Charles, musician
Eric Clapton, musician
Dick Clark, television personality
Leonard Cohen, musician, writer
Francis Ford Coppola, director
Michael Crichton, writer
Kathy Conkrite, writer
Sheryl Crow, musician
Mike Douglas, media personality
Tony Dow, actor, director
Famous Living Unipolars
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James Farmer, civil rights activist
John Kenneth Galbraith, economist, educator, author
Mariette Hartley, actor
Anthony Hopkins, actor
Robert McFarlane, former US National Security Advisor
Joan Rivers, comedienne, talk show host
Roseanne, actor, writer, comedienne
Rod Steiger, actor
William Styron, writer
James Taylor, musician
Livingston Taylor, musician
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Mike Wallace, news anchor
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Marie Osmond, entertainer
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Mood Disorders
Classification and
Demographics ...
Mood Disorders (DSM-IV)
Depressive Disorders
– Major Depressive Disorder (single/recurrent)
– Dythymic Disorder
– Depressive Disorder, NOS
Bipolar Disorders
–
–
–
–
Bipolar I
Bipolar II
Cyclothymic Disorder
Bipolar Disorder, NOS
Mood Disorder due to:
– Medical condition
– Substance induced
Mood Disorders - DSM IV
Unipolar vs Bipolar
Unipolar
Prev
Gender
Onset
Suicide
Sleep
Rx
Genetics
5%
F>M
30’s
15%
insom
unipolar
lower
Bipolar
1%
F=M
20’s
20%
hyper
bipolar III
higher
Epidemiology
 Lifetime risks:
– Major Depression: 6 %
– All mood disorders: 8 %
 Prevalence
– Major Depression: (point prevalence approx 5 -6 %)
• Males: 2.6 - 5.5%
• Females: 6.0 - 11.8 %
– Dysthymia: 3 - 4 %
– In primary care practice:
• Major Depression: 4.8 - 9.2 %
• All depressive disorders: 9 - 20 %
 Bipolar Disorder: 1.0 - 2.5 %
 5 - 15 % of adult depressions are bipolar
Prevalence of Mood Disorders
 20% of the U.S. population reports at least one
depressive symptom in a given month
 12% report two or more depressive symptoms in
a year
 Major Depression: 5% in the previous 30 days,
 Bipolar Disorder - approximately 1 % of the
population
 Increase in cohort post 1940
 Younger age of onset
Genetics
 Unipolar
– Dizygotic: 30%
– Monozygotic: 50%
– Family history: 25%
 Bipolar
– Dizygotic: 30%
– Monozygotic: 80%
– Family history: 50%
Gender differences
 Bipolar - no difference
 Unipolar - Female > Male
– ?genetic
– sociocultural
– alcoholism/substance abuse
Mood Disorders: Across the Lifespan
 Infancy - Spitz and Harlow
 Childhood - depressive equivalents
 Adolescence - major onset;
substance abuse
 Adulthood - major onset
 Geriatric - multiple symptoms;
pseudodementia; differential
medical diagnoses
Predisposing factors
 Prior mood disorder or moodswings
 Positive family history
 Female gender
 Severe prolonged stress
 Recent loss
 Postpartum period
 Medical co-morbidity
 Current alcohol/substance abuse
Prognosis
 Major Depression recurrence rates:
1 episode:
50 - 60%
2 episodes:
70%
3 episodes:
90%
 Untreated episode: 6-12 months
 20-30 % chronicity
 Episode length and frequency: shorter
episodes with increasing frequency
 Treatment yields good results
Mood Disorders
Clinical Syndromes ...
Hypomania:
What does it feel like?
“At first when I'm high, it's tremendous...ideas are
fast...like shooting stars you follow until brighter
ones appear...all shyness disappears, the right
words and gestures are suddenly
there...uninteresting people, things, become
intensely interesting. Sensuality is pervasive, the
desire to seduce and be seduced is irresistible.
Your marrow is infused with unbelievable
feelings of ease, power, well-being,
omnipotence, euphoria...you can do
anything...but, somewhere this changes”.
Mania:
What does it feel like?
“The fast ideas become too fast and there
are far too many...overwhelming
confusion replaces clarity...you stop
keeping up with it--memory goes.
Infectious humor ceases to amuse. Your
friends become frightened...everything is
now against the grain...you are irritable,
angry, frightened, uncontrollable, and
trapped”.
Clinical Mania
 A sustained period of behavior that is different
from usual
 Increased energy, activity, restlessness,
 Racing thoughts and rapid talking
 Excessive "high" or euphoric feelings
 Extreme irritability and distractibility
 Decreased need for sleep
 Unrealistic beliefs in one's abilities and powers
 Uncharacteristically poor judgment
>>
Clinical Mania
 Reckless behavior
 Increased suspiciousness/paranoid ideation
 Increased sexual drive
 Abuse of drugs, particularly cocaine, alcohol,
and sleeping medications
 Flight of ideas
 Provocative, intrusive, or aggressive behavior
 Possibly delusions
(paranoid/grandiose/religious)
 Possibly hallucinations
 Denial that anything is wrong
Cycle Length
Bipolar: Frequency of Recurrence
Hypomania
 Inflated self-esteem
 Decreased need for sleep
 More talkative than usual
 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)
 Increased activity
 No major life disruption
 No need for hospitalization
 No psychotic symptoms
Cyclothymia
 Alternating hypomania and
non-major depression
 At least 2 years in duration
Depression:
What does it feel like?
“I doubt completely my ability to do
anything well. It seems as though my mind
has slowed down and burned out to the
point of being virtually useless....[I am]
haunt[ed]...with the total, the desperate
hopelessness of it all... Others say, "It's
only temporary, it will pass, you will get
over it," but of course they haven't any
idea of how I feel, although they are
certain they do. If I can't feel, move, think,
or care, then what on earth is the point?”
Sadness vs Clinical Depression
 Intensity
 Duration
 Neurovegetative changes
 Self esteem changes
 Normal Grief vs. Depressive Illness
Depressive Disorders - DSM - IV
 Major Depressive Disorder (296.xx)
 Dysthymic Disorder (300.4)
 Depressive Disorder NOS (311)
 Mood Disorder due to general
medical condition (293.83)
 Substance-Induced mood disorder
(293.83)
Clinical Depression
 Loss of the ability to experience
pleasure
 Unexplained or prolonged sadness or
crying spells
 Significant changes in appetite and
sleep patterns
 Diurnal variation of mood
 Irritability, anger, worry, agitation,
anxiety
 Pessimism, indifference
 A sense of hoplessness/helplessness

Clinical Depression
 Loss of energy, persistent lethargy,
pathological fatigue
 Feelings of guilt, worthlessness
 Inability to concentrate, indecisiveness
 Social withdrawal
 Difficulty with personal hygiene
 Unexplained aches and pains
 May have delusions or hallucinations
 Recurring thoughts of death or suicide
Other Specifiers
Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
Physical Symptom
Indicators
 Fatigue
 Pain
 Sleep disturbances
 GI disorders (IBS)
– unexplained by medical testing
Atypical Presentations
 Anxiety/panic symptoms
 Irritability
 Hysterical symptoms
 Hypochondriacal symptoms
 Unexplained pain syndromes
 Substance abuse presentations
 “Personality disorder”
Dysthymia
 This disorder is characterized by a
chronic state of depression,
exhibited by a depressed mood on
most days for at least 2 years. (1
year in children and adolescents).
 There are no psychotic symptoms
.
Dysthymia: symptoms and
duration
 poor appetite or overeating
 insomnia or hypersomnia
 low energy or fatigue
 low self-esteem
 poor concentration or difficulty making
decisions
 feelings of hopelessness
Dysthymic individuals must not have gone for more than 2 months
without experiencing two or more of these symptoms
Mood Disorders
Suicide ...
Suicide Rates in Mood Disorders
Unipolar: 15 %
Bipolar: 20 %
Suicide Risk Factors
 Clinical depression
 Suicidal ideation
 Self oriented (non-manipulative)
 Available lethal method
 Male>Female
 White>black
 Elderly
 Loss with alcohol/substance abuse
Suicide Rates
Suicide - Clusters
Mood Disorders
Causes
and
Treatments ...
Psychological Models
 Psychoanalytic
 Interpersonal
 Cognitive
 Behavioral/learned helplessness
Treatment: Psychological
 Individual Psychotherapy
– Psychodynamic/Psychoanalytic
– Cognitive
– Interpersonal
– Supportive
 Group Therapy
 Couples Therapy
 Family Therapy
Biological Models
 Genetic
 Neurotransmitter dysfunction
 Neuroendocrine dysfunction
 Chronobiological
 Sensitization/Kindling
Serotonergic pathways
Neurotransmission
Neurons
Basic Synapse
Serotonin Synapse
Reuptake pump
Synaptic Interactions
Synaptic Transmission
Biological Markers in Major
Depression
DST
TRH/TSH
Shortened REM latency
Treatment: Biological
 Antidepressants
 Antipsychotics (typical, atypical)
 Mood stabilizers (thymoleptics)
 Augmentation strategies
 Herbal
 Phototherapy
 ECT
 rTMS
Mood Stabilizing Medications
 Lithium carbonate/citrate
 Tegretol (carbamazepine)
 Depakote (valproic acid)
 Neurontin (gabapentin)
 Lamictal (lamotrigine)
 Klonopin (clonazepam)
 Zyprexa (olanzapine)
Antidepressant Medication
 Antidepressant medications are non-
addictive.
 Another antidepressant can be tried
should the first have unacceptable sideeffects.
 Antidepressants take time to work
 Physical symptoms are more likely to
respond before psychological symptoms
 Undulating improvement
Antidepressant
medications
 TCA’s (imipramine, nortriptyline, desopramine)
 MAOI’s (phenelzine, tranylcypromine, meclobemide)
 SSRI’s (fluoxetine, sertraline, paroxetine, fluvoxamine,
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citalopram)
SNRI’s (venlafaxine)
CRI’s (buprorion)
Alpha2 adrenergic antagonists (mirtazapine)
Serotonin2A antagonists and serotonin reuptake inhibitors
(trazodone, nefazodone)
Modified amino acids (SAMe)
Psychostimulants
Augmentation strategies (Li, T3, buspirone, anxiolytics )
Electroconvulsive Therapy
(ECT)
 History
 Indications
 Efficacy
 Adverse effects
 Safety
rTMS
Integrative Treatments
 Nature AND Nurture
 In major syndromes: combinations
of medication and psychotherapy
 Treat the individual
 Never give up