Download Adult Mood Disorders Dr Gillis 2010

Mood Disorders: A Biopsychosocial
Approach
Katharine Gillis FRCPC
Associate Professor
Department of Psychiatry
University of Ottawa
MOOD DISORDERS
 Major Depressive Disorder
 Dysthymic Disorder
 Bipolar Disorders:
I
with Mania
II with hypomania
 Cyclothymia
LIFETIMES PREVALENCES
 Major Depressive Disorder
women
10-25 %
men
5-12%
 Dysthymia
6%
 Bipolar Disorders
type I 0.4-1.6 %
type II
0.5%
In the Family Practice Setting
 25% of all patients who visit their family
physicians will have a diagnosable mental
disorder
 The incidence of major depression is 10% in
primary care patients
 Effective treatment can reduce morbidity and
decrease utilization of other health services
 Medical patients with major depression have a
worse prognosis for their medical recovery
Key Concepts in Mood Disorders
 Mood Disorders are usually EPISODIC
 Need to inquire about current episode, but
also past episodes
 Past history of episodes that are high or low
are the often the key to sorting out the
diagnosis
 Genetics are very important in mood
disorders especially Bipolar: ALWAYS ask
about family history of mood symptoms or
suicide
Key Concepts in Mood Disorders
 Is there a history of inter episode wellnessbetter prognosis
 Are the symptoms chronic
 Treatment goal is to treat current
symptoms but also to try and prevent
future episodes of mood symptoms
 Treatment usually medication based for
moderate to severe symptoms plus or
minus a specific type of psychotherapy.
How is Major Depression different from just
feeling down?
 Just feeling down should not have “physical
symptoms” associated with it
 Just feeling down should not impair
function
 Just feeling down should not last daily for
at least two consecutive weeks or more
 Untreated an episode of major depression
on average lasts 6-12 months
Key Concept for Major Depression
 For Major Depression must have persistent
symptoms of depression or LOSS of
INTEREST for at least 2 consecutive weeks
 Many people with depression do NOT report
feeling depressed, but have loss of interest
 Elderly patients often have new onset of
somatic complaints but may deny feeling
depressed
 Need a cluster of four other symptoms
besides loss of interest or depression to
make the diagnosis
Key Concept for Major Depression
 Physical symptoms of depression include
changes FROM BASELINE in sleep, appetite,
energy and physical movements
 Physical symptoms are often referred to as
“vegetative symptoms”
 The presence of new onset of vegetative
symptoms can be a good predictor of
response to antidepressant treatment
Physical Symptoms of Major Depression
 Sleep- change from baseline. Usually
too little.
 All sleep phases can be effected but the
classic symptom is early morning
awakening.
 Excessive sleep from baseline is an
atypical feature and occurs more in
teenagers
Physical Symptoms of Major Depression
 Appetite-change from baseline usually a
decrease
 Loss of taste for food*
 Loss of weight
 Increase in appetite from baseline,
especially with carbohydrate craving is
an atypical feature and occurs more in
teenagers
Physical Symptoms of Major Depression
 Fatigue- change from baseline
 Diminished spontaneous movements
may be observed and is called
psychomotor slowing
 Physical restlessness may be observed
and is called psychomotor agitation
Other Important Symptoms of Major
Depression
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Guilt
Impaired concentration
Social withdrawal
Suicidal thoughts: Safety assessment
Panic attacks*
Obsessive compulsive symptoms*
*Not in DSM-4 criteria
Specifiers for Mood Disorders
 Specifiers describe the most recent
mood episode such as:
 With Postpartum Onset (within 4
weeks of delivery
 With Catatonic features
 With Atypical Features
 With Rapid Cycling
Specifier- With Seasonal Pattern
 Only applies to Major Depressive Episode (not manic
or hypomanic)
 Regular temporal relationship between onset of major
depressive episode and a particular time of year
usually fall or winter
 Full remission also occurs at regular time of year
usually spring (or switch to mania)
 In the last 2 years two major depressive episodes
have occurred as above with no nonseasonal episode
of MDE occurring in the two years
 Seasonal episodes of MDE outweigh nonseasonal
episodes in their lifetime
Specifier-With Psychotic Features
 Psychosis may be present in 10-15% of
patients with a Major Depressive Episode
 Associated with worse prognosis
 Increase risk of suicide and homicide
 Important to always screen for psychotic
symptoms
 Has treatment implications- antipsychotic
needs to be added to antidepressant. May be
an indication to consider ECT.
Epidemiology of Major Depression.
Who is at risk?
 Prevalence for men 5-12%, women 1025%
 Mean age of onset is around 40
 50% of all patients have onset between
the ages of 20 and 50
 10% of post partum women are at risk
of Major Depressive Episode. Etiology
remains unclear, stress vs. hormone
Epidemiology of Major Depression.
Who is at risk?
 No correlation between socioeconomic
status and MDE but unemployed are at 3X
more risk
 MDE more common in rural than urban
areas
 Prevalence of mood disorder does not vary
among races
 Loss of a parent before age 11 is a risk
 Loss of a spouse is a risk
Recurrence Rates in Major Depression
 After 1 episode
 After 2 episodes
 After 3 episodes
50 %
75 %
90 % +
DYSTHYMIA
 Depressed mood most days for 2 years
 Depressed symptoms include:
appetite disturbance
sleep disorder
fatigue
low self-esteem
poor concentration
hopelessness
indecision
DYSTHYMIA (cont.)
 Never symptom-free for over 2
months
 Symptoms cause impaired functioning
 Antidepressant may or may not be
helpful. Psychotherapy may help
particularly if many negative cognitions.
Bipolar Disorder
 Bipolar disorder is characterized by the
occurrence of mood episodes, usually with
inter-episode wellness.
 A mood episode can be a major depressive,
manic, hypomanic, or mixed episode
 An episode is demarcated by either switch
to an opposite state ( manic to depressive)
or 2 months or more of partial or full
remission after an episode
Bipolar Type I
 Prevalence 1% of population men=women
 Must have at least one Manic Episode
 Does not require a depressive episode but
most patients have depression in their
lifetime
 Most have more depressive than manic
episodes
 Manic episodes are not subtle and usually
require hospitalization
Manic Episode Criteria
 Elevated mood (may be irritable, expansive)
persisting for at least one week
 Need 3 (or 4 if irritable) of the following:
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Grandiosity
Delusions
Reduced sleep
Talkative
Racing thoughts (flight of ideas)
Distractibility
Psychomotor agitation
Poor impulse control, excessive involvement in
pleasurable activities
Manic Episode Criteria
 Severe, marked impairment in function
at work or socially, or need for
hospitalization or presence of psychotic
features
 Symptoms present at least one week
 Condition not caused by general
medical condition or substances
Mixed Episode Criteria
 Criteria are met for both a manic episode
and a major depressive episode (except for
duration) nearly every day for 1 week
 Severe, marked impairment in function at work
or socially, or need for hospitalization or
presence of psychotic features
 Condition not caused by general medical
condition or substances
Bipolar I
 Average onset for first manic episode is age
32
 Most have had 2-3 episodes of depression
by history prior to first manic episode
 Symptoms of acute mania develop over
hours to days
 Untreated manic episode lasts 3 months
 Untreated depressive episode lasts 6-13
months
Bipolar II
Must have hypomanic episode(s) not manic
Prevalence 0.5 % population
May have major depressive episodes
Less functional impairment than Type 1
Often does not require hospitalization
If patient looks hypomanic but delusions
present then diagnose as manic
 Did an antidepressant cause the hypomanic
symptoms? If so may be Bipolar III.
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Hypomanic Episode
 Elevated, expansive or irritable mood
lasting at least 4 days
 Need 3 (or 4 if irritable) of the following:
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Grandiosity
Delusions
Reduced sleep
Talkative
Racing thoughts (flight of ideas)
Distractibility
Psychomotor agitation
Poor impulse control, excessive involvement in
pleasurable activities
Hypomanic Episode
 Unequivocal change in functioning from
baseline
 The disturbance in mood and the change in
functioning is observable by others
 The episode is NOT severe enough to cause
marked impairment in work or social
functioning, or to need hospitalization, no
psychotic features
 Symptoms are not caused by a general
medical condition or substances
Rapid Cycling Bipolar Disorder
 Can be applied to Bipolar I and II
 At least four mood episodes in previous 12
months- depression, mania, hypomania,
mixed state
 Episode demarcated by either switch to
opposite state or 2 months of partial or full
remission between episodes
 Rapid cycling diagnosis has treatment
implications
CYCLOTHYMIA
 Numerous periods of depressive
symptoms AND hypomania symptoms
over 2 years
 Never symptom free for 2 months
 No time of Major Depression or Mania
 Symptoms cause impaired functioning
Common Medical Conditions
Associated with Mood Disorders
 Hypo/hyper thyroidism
 Cardiovascular disease especially MI
 CNS- infection, tumour, stroke, head injury,
hypoxia
 Parkinson's, Huntington's, Multiple Sclerosis
 B12, folate deficiency
 Chronic pain
 Sleep Apnea
Drugs Commonly Associated with
Mood Disorders
 Steroids, corticosteroids –
depression, mania, anxiety
 Accutane isoretinoin
 Oral contraceptives, progesterone
 Interferon A
 Evidence for Beta Blockers is weak