MOOD DISORDERS

Epidemiology

Sex: MDD F:M = 2:1 BID F = M

Age: onset - BID is earlier (30 yo) than MDD (40yo)

Marital Status: MDD - no close interpersonal relationships, divorced, separated

BID - single/divorced > marriedSE & Cultural Considerations

Etiology

1. Biological Factors: abN in biogenic amine metabolites (5-HIAA, HVA, MHPG)

1. Biogenic Amines - NE, 5HT, DA, GABA2. Neuroendocrine regulations

1. Hypothalamus1. Adrenal axis2. Thyroid axis3. Growth hormone

3. Sleep Abnormalities - EEG abN4. Kindling5. Circadian Rhythm6. Neuroimmune Regulations7. Brain Imaging - CT scan, MRI8. Neuroanatomical Considerations - limbic

system, basal ganglia, hypothalamus

2. Genetic Factors - BID > MDD1. Family Studies2. Adoption Studies3. Twin Studies

3. Psychosocial Factors1. Life events & Environmental stress2. Premorbid Personality Factors3. Psychoanalytic & Psychodynamic Factors4. Learned Helplessness5. Cognitive Theory

Diagnosis

Major Depressive Disorder– Depressed mood– Loss of interest or pleasure– Weight loss or gain– Insomnia/hypersomnia– Psychomotor agitation or retardation– Fatigue or loss of energy– Feelings of worthlessness or inappropriate guilt– Diminished ability to think or concentrate– Recurrent thoughts of death– Sxs cause significant distress or impairment

Manic Episode– Elevated, expansive, or irritable mood– Inflated self-esteem or grandiosity– Decreased need for sleep– More talkative– Flights if ideas– Distractibility– Psychomotor agitation– Excessive involvement in pleasurable

activities

Clinical Features

Depressive Episodes– Depressed mood: feel blue, sad, hopeless,

worthless– Agonizing emotional pain– 2/3 contemplate suicide– 10 - 15% commit suicide– 97% - reduced energy– 80% - sleep disturbance– Decreased appetite– 90% - anxiety

Atypical Features– Hysteroid Dysphoria– Increased appetite– Weight gain– Hypersomnia

Depression in Children and Adolescents– School phobia– Poor academic performance– Substance abuse– Antisocial behavior– Sexual promiscuity– Truancy– Running away

Depression in the Elderly– More common - 25-50%– More somatic complaints

Manic Episodes– Elevated, expansive, irritable mood– Infectious– Disinhibited– Impulsive– Preoccupied by religious, political,

financial, sexual or persecutory ideas

Manic in Adolescents– Misdiagnosed as antisocial PD or

schizophrenia– Psychosis, substance abuse, suicide

attempts, academic problems, somatic complaints, irritability

Co-existing Diagnosis

1. Anxiety2. Alcohol dependence3. Other substance-related disorder4. Medical conditions

Mental Status Examination

Depressive Episodes1. General Description - retardation,

agitation2. MAF - depression3. Speech - decreased rate and volume4. Perceptual Disturbances

1. With perceptual disturbances2. Psychotic depression3. Mood-congruent4. Mood-incongruent

5. Thought - negative view of the world and themselves

1. Content - loss, suicide, guilt, death2. Thought blocking

6. Sensorium and CognitionMemory: 50-75% depressive dementiaImpaired concentration & forgetfulness

7. Impulse Control10-15% - complete suicide2/3 cases - suicide ideationParadoxical suicide

8. Judgment and Insightexcessive insight

9. Reliabilitypoor

Manic Episodes1. General Description - excited, talkative,

hyperactive2. MAF - euphoric, irritable, angry, hostile,

labile3. Speech - disturbed, loud, rapid,

pressured4. Perceptual disturbances - 75%

delusional

5. Thought1. Content: self-confidence, self-

aggrandizement2. Form: looseness of association, flight of

ideas, word salad, neologisms3. Cognitive function: unrestrained, accelerated

flow of ideas

6. Sensorium and Cognitionorientation and memory intact

7. Impulse Control - 75% assaultive and threateningattempt suicide and homicide

8. Judgment and Insightimpaired judgment - hallmarklittle insighht

9. Reliabilitynotoriously unreliablelying and deceit

Differential Diagnosis

MDD1. Medical Disorders - medications, neurological

conditions2. Mental Disorders

1. Mood DO due to General Medical Condition2. Substance-Induced Mood DO

3. Other Mental DO - SRD, psychotic DO, eating DO, adjustment DO, anxiety DO, somatoform DO

4. Uncomplicated Bereavement

BID1. Medical DO2. Mental DO - BIID, cyclothymia, Mood

DO due to General Medical Condition, Substance-Induced Manic episode, Borderline PD, Narcissistic, Histrionic, Antisocial PDs, Schizophrenia

Course and Prognosis

Chronic, tend to have relapsesMDD Course

– Onset: 50% before age 40 years– Duration: untreated 6-13 months

– treated 3 months– Development of manic episodes: 5-10%

with initial diagnosis MDD have manic episode 6-10 years after

– Mean age of switch = 32 years old

– Prognosis: chronic, tend to relapseIndicators: GOOD - mild episodes, (-)

psychosis, short hospital stay, (+) social support, (-) comorbidity, advanced age of onset

POOR - co-existing dysthymic DO, abuse of alcohol and other substances, anxiety DO sxs, hx of more than one episode of depression

BID Course– Most often starts with depression– Recurring disorder– Manic episode has rapid onset– Prognosis: poorer prognosis than MDD

40-50% have 2nd manic episode within 2 years

50-60% are controlled with lithium

Indicators: GOOD - short duration, advanced stage of onset, few suicidal attempts, few coexisting psych or medical problems

POOR - poor occupational status, alcohol dependence, (+) psychosis, depressive features, males

Treatment

GOALS1. Safety of the patient2. Complete diagnostic evaluation3. Treatment plan

Treatment must reduce the number and severity of the stressors in patients’ lives

1. Hospitalization• Indications: prognostic procedures

risk of suicide and homicide

grossly regressed

2. Psychotherapy• Short-term psychotherapy: cognitive,

interpersonal, bahavior

3. Pharmacotherapy– MDD: 3-4 weeks– principal indication: major depressive episode– Patient education

Alternatives to Drug Therapy: ECT and phototherapy

ECT: unresponsive to pharmacotherapy cannot tolerate pharmacotherapy severe situations that rapid improvement is needed

PHOTOTHERAPY: with seasonal pattern; mild

Guidelines: Dosage of antidepressant should be raised to the maximum recommended level and maintained at that level for at least 4 weeks.

Duration and Prophylaxis: Antidepressant treatment should be maintained for at least 6 months.

– BID: lithium, carbamazepine, valproateLithium: standard treatment

SE: renal, nervous, metabolic, GI, derma, thyroid

Anticonvulsants: carbamazepine, valproateOther agents: clonazepam, clonidine,

clozapine, verapamil

Dysthymic Disorder

EPIDEMIOLOGY– Common; 3-5% of all persons– Females (less than 65yo) > men– Frequently coexists with other mental Dos

ETIOLOGY1. Biological Factors

1. Sleep studies2. Neuroendocrine axis

2. Psychosocial Factors1. Faulty personal and ego development2. Defense mechanism: reaction formation3. Low self-esteem, anhedonia, introversion

DIAGNOSIS– Depressed mood most of the time for at

least 2 years– (-) manic or hypomanic episodes

CLINICAL FEATURES– Chronic– Severity of depressive symptoms is

generally less– Sarcastic, nihilistic, brooding, demanding,

complaining– (-) psychotic symptoms

– Associated symptoms:Changes in appetite and sleep patternsDecreased sexual driveLow self-esteemLoss of energyPsychomotor retardationPessimism, hopelessness, helplessnessSocial impairment

CO-EXISTING DIAGNOSIS1. Double Depression - poorer prognosis2. Alcohol and other substance abuse -

alcohol, stimulants, MJ DIFFERENTIAL DIAGNOSIS

1. Minor Depressive DO2. Recurrent Brief Depressive DO

COURSE AND PROGNOSIS– 50%: insidious onset before age 25 years– 25%: progressed to MDD– 15%: BIID– <5%: BID

TREATMENT– Pharmacotherapy + cognitive/behavior tx

Cyclothymic Disorder

Mild Bipolar II DisorderHypomania and mild depression

EPIDEMIOLOGY– 3-10% of all psychiatric patients– 1% lifetime prevalence– Frequently co-exists with Borderline PD– F:M = 3:2– Onset between 15-25 years old (50-75%)

ETIOLOGY1. Biological Factors

– Genetic: 30% (+) history of BID

2. Psychosocial Factors– Trauma and fixation during oral stage– Freud: ego attempts to overcome a harsh

and punitive superego

DIAGNOSIS– Symptoms at least 2 years

CLINICAL FEATURES– Less severe symptoms of BID– Hypomanic symptoms– Mixed symptoms with marked irritability– Shorter cycles

Substance Abuse: to self-medicate or to achieve further stimulation

DIFFERENTIAL DIAGNOSIS1. Medical and Substance-Related causes

of depression and mania2. Borderline, antisocial, histrionic,

narcissistic PDs3. ADHD

COURSE AND PROGNOSIS– Insidious onset; teens or early 20’s– 1/3 go to major mood DO, most often

BIID TREATMENT

1. Biological tx: antimanic - LiCO32. Psychosocial tx: directed towards

patients’ insight and coping mechanisms for their mood swings