Download Other Mood Disorders

Mood Disorders
Archetypes
• Depression
– Major Depression
• Mania
– Bipolar Disorder (Manic-Depression)
Phenomenology:
The Mental Status Exam
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General Appearance
Emotional
Thought
Cognition
Judgment and Insight
Reliability
General Appearance
• Depression
• Mania
Emotions: Depression
• Mood
– Dysphoric
– Irritable, angry
– Apathetic
• Affect
– Blunted, sad, constricted
Emotions: Mania
• Mood
– Euphoric
– Irritable
• Affect
– Heightened, dramatic, labile
Thought: Depression
• Process
– Slowed processing
• Thought blocking
• Content
• Everything’s awful
• Guilty, self-deprecating
• Delusional
Thought: Mania
• Process
– Rapid
– Pressured speech
– Loosening of Associations
• Content
– Grandiose
– Delusions
Cognition
• Depression
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Poor attention
Registration
Effort
“Pseudodementia”
• Mania
– Distractible
– Concentration
– May seem brighter, more clever
Insight and Judgment
• Depression
– Unrealistically negative
• Mania
– Unrealistically positive
– Or just plain bad
Diagnosis and Criteria
• Episodes Versus Disorders
Episodes
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Major depressive
Manic
Mixed
Hypomanic
Major Depressive Episode
• Time
– 2 weeks
• Change
– From previous functioning
• Symptoms
– 5 or more
– 1 has to be depressed mood or anhedonia
• Global Criteria
Symptoms of Major Depressive
Episode
• “Sig E Caps”
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Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor retardation
Suicide
• 5 or more
Manic Episode
• Time
– 1 week
• Symptom list
– 3 or more
• Global Criteria
Symptoms of Manic Episode
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Grandiosity
Decreased need for sleep
Pressured Speech
Flight of Ideas
Distractibility
Increased Activity/Agitation
Risky Activities
• 3 or more
The Disorders
Major Depressive Disorder
• “Classic Depression”
• Major Depressive
Episode
• Rule outs
– Some other disorder
– History of
mania/hypomania
Bipolar Disorder I
• Classic “Manic-Depression”
• At least one
– Manic or,
– Mixed episode
Epidemiology
• Depression
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5-7%
2:1 ♀:♂
$53 billion/year in US
World: most costly
(developed)
Epidemiology
• Bipolar Disorders
– 1%
– ~1:1 ♀:♂
Etiology and Pathophysiology
Genetics
• Family studies
– Higher rates
– Breed true?
• Twin Studies
– Mono:Di ~4:1
• Linkage studies
– Numerous (? Consistency)
– Recent: Zubenko, Am J Genetics
Social/Environmental
• Response to Loss
– ex. Animal models
• Other stress
– Ex. Learned helplessness
• What is role of social stress?
– Ex. Nemeroff et al.
Neurotransmission
• Neurochemical hypotheses
– Catecholamine hypothesis
• Norepinephrine
– Ex. Axelrod
– Depletions models
• Serotonin
– Refinements
• Imbalances
• Receptors
• 2nd messengers
Neuroimaging
• Stroke data
– Dominant frontal
– Basal ganglia
• Fx Imaging
Other Physiological Findings
• Neurophysiology
– Circadian rhythms and sleep
• Neuroendocrine
– HPA axis
• DST
Differential Diagnosis
“We’re not living happily
ever after any more”
Differential Diagnosis
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Psychiatric Disorders
Medical Disorders
Substance Induced
Reactive disorders
– Adjustment disorders
– Normal reactions
Comorbidity
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Anxiety disorders
Substance abuse
Psychotic disorders
Personality disorders
Depression in the
medically ill.
Comorbidity
Course and Prognosis of Mood
Disorders
Course and Prognosis of Mood
Disorders
• Recovery
• Relapse
• Recurrence
90
80
70
60
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40
30
20
10
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0.5
1
2
Recovery
4
5
Predictors
• # Episodes
• Length of episodes
• Symptoms
– # and type
• Comorbidity
Risk of Suicide
• Depression
– 10-15% severe (hosp) pts
Treatment
“It is unfortunate
that I didn’t get
your care earlier,
Mrs. Perkins.”
Treatment
• Depression
– Pharmacological
– Psychotherapy
– Other somatic treatments
Antidepressants
Antidepressants
• 1st generation
– Monoamine Oxidase Inhibitors (MAOIs)
– Tricyclic Antidepressants (TCAs)
• 2nd
– Serotonin reuptake Inhibitors (SSRIs)
– Other specifics (Buproprion, Trazodone)
• 3rd
– Venlafaxine, Mirtazapine, Nefazodone
Mechanisms of action
• Monoamine Action
– Increase
• Norepinephrine
• Serotonin
– Various mechanisms
• Inhibition of catabolism (MAOIs)
• Reuptake inhibition (TCAs, SSRIs, Venlafaxine)
• Direct effects (agonism/antagonism) (some 3rd gen)
Side effects
• Predicable
– Anticholinergic
– Antihistaminic
– Serotonergic
• Idiopathic
Choice of antidepressant
• Best?
• Fastest?
• Predictors of response
– Past history
– Family history
• Major difference
– Side effects
Treatment failure
• Inadequate dose
• Inadequate time
• Nonadherence
Strategies for failure
• Choices
– Increase dose?
– Augment?
– New drug?
Lithium
Thyroid hormone
Stimulants
Atypical Antipsychotics
2nd Antidepressant
Long term treatment
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Recurrent depression (3+)
Chronic depression (2 years)
Double depression
Others
Psychotherapy
• Cognitive behavioral
therapy
• Interpersonal therapy
• Others
Medications versus therapy
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Severe depression
Moderate depression
Combination treatment
Prevention
Other treatments
• ECT
• TMH
• Vagal nerve stimulation
ECT
• Maybe the best.
• Medication failure
• Real serious
depression
• Time sensitive
• So why don’t we give
everybody ECT?
Bipolar Disorder
• Lithium
• Antipsychotics
• Anticonvulsants
Lithium
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First line
Best for mania
2 weeks for effect
Therapeutic index
Side effects
Acute and preventive
Anticonvulsants
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Sodium Valproate
Carbamazapine
Lamotrigine
Gabapentin
Antimanic
Antidepressant
Prevention
Side effects
Antipsychotics
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Atypical (olanzapine)
Classic
May be as effective
Early and late effect
Sedatives
• Acute use
Other Diagnoses
Other Episodes
• Mixed
• Hypomanic
Other Mood Disorders
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Dysthymic Disorder
Cyclothymic Disorder
Bipolar II
Due to a generalized medical condition
Substance Induced
NOS