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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 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 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 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 Mike Wallace, news anchor Marie Osmond, entertainer 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, 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