Mood (Affective) Disorders

Department of Psychiatry 1st Faculty of Medicine Charles University, Prague Head: Prof. MUDr. Ji Raboch, DrSc.

Mood (Affective) Disorders

Mood disorders are very common, their life prevalence is up to 20 %, and they have a high level of morbidity and mortality as well as an immense impact on disabilities worldwide. The fundamental disturbance is a change in mood or affect, usually to depression (with or without associated anxiety) or to elation. The mood change is usually accompanied by a change in the overall level of activity. Most of these disorders tend to be recurrent, and the onset of individual episodes is often related to stressful events or situations. The mood disorders may be subdivided into unipolar and bipolar types:
1. those that are characterized by depression only 2. those that are characterized by manic episode either alone or in combination with depression

Classification of Mood Disorders

International Classification of Diseases (ICD10) came into use in WHO Member States as from 1994 F30 F31 F32 F33 F34 F38 F39 Manic episode Bipolar affective disorder Depressive episode Recurrent depressive disorder Persistent mood (affective) disorders Other mood (affective) disorders Unspecified mood (affective) disorder

Test Methods

Self-reported scales:
Young Mania Rating Scale (YMRS) Beck scale (depression) Zung scale (depression)

Interview with physician:

Hamilton scale (HAMD) Montgomery and Asberg scale (MADRS)

F32 Depressive Episode

Pathological sadness Depressive episode:

depressed mood loss of interest and enjoyment reduced energy leading to increased fatigability and diminished activity marked tiredness after only slight effort reduced concentration and attention reduced self-esteem and self-confidence ideas of guilt and unworthiness bleak and pessimistic views of the future ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite

F32 Depressive Episode

Clinical presentation shows marked individual variations

in some cases, anxiety, distress, and motor agitation may be more prominent at times than the depression the mood change may also be masked (masked depression) by added features such as irritability, excessive consumption of alcohol, histrionic behaviour, and exacerbation of pre-existing phobic or obsessional symptoms, or by hypochondriacal preoccupations.

Depressive episode should last at least 2 weeks (typically several months), but shorter periods may be reasonable if symptoms are unusually severe and of rapid onset. The lifetime prevalence: 17%; risk of recurrence >50%.

F32 Depressive Episode

The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called somatic symptoms:
loss of interest or pleasure in activities that are normally enjoyable (anhedonia) lack of emotional reactivity to normally pleasurable surroundings and events waking in the morning 2 hours or more before the usual time

depression worse in the morning

objective evidence of definite psychomotor retardation or agitation loss of appetite

weight loss
loss of libido

F32 Depressive Episode

F32 F32.0 F32.1 F32.2 Depressive episode Mild depressive episode Moderate depressive episode Severe depressive episode without psychotic symptoms F32.3 Severe depressive episode with psychotic symptoms F32.8 Other depressive episodes F32.9 Depressive episode, unspecified

F32.0 Mild Depressive Episode

Two or three of the above symptoms are usually present. For mild depressive episode are typical depressed mood, anhedonia and increased fatigability. The afflicted person is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

F32.1 Moderate Depressive Episode

An individual with moderate depressive episode suffers from more symptoms (four or more of the above symptoms are usually present) of greater severity and will usually have considerable difficulty in continuing with social, work or domestic activities.

F32.2 Severe Depressive Episode without Psychotic Symptoms

In a severe depressive episode, the sufferer usually shows considerable distress or agitation. Loss of self-esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in particularly severe cases. ; a number of "somatic" symptoms are usually present.
Agitated depression Major depression Vital depression

F32.3 Severe Depressive Episode with Psychotic Symptoms

Psychotic symptoms may be present, such as

delusions (ideas of sin, poverty or imminent disasters) hallucinations (defamatory or accusatory voices or of rotting filth or decomposing flesh) depressive stupor

Severe ordinary social activities are impossible When the psychotic symptoms are consistent with the patients mood, they are referred to as mood congruent, when they are inconsistent, they are referred as mood incongruent. Single episodes of:
major depression with psychotic symptoms psychogenic depressive psychosis psychotic depression reactive depressive psychosis

F33 Recurrent Depressive Disorder

Recurrent depressive disorder is characterized by repeated episodes of depression without any history of independent episodes of mood elevation and overactivity. Recovery is usually complete between episodes, but a substantial part of patients will have a recurrence and about 30% may develop a persistent depression. The lifetime prevalence - about 1020 %; women:men 2:1. The risk of suicide (approximately 1015%. Seasonal affective disorder - onset of mood symptoms is connected with changes of seasons, with depression typically occurring during the winter months and remissions or changes from depression to mania occurring during the spring.

F33 Recurrent Depressive Disorder

remission severity of depression no depression recovery recurrence relapse relapse response

symptoms

syndrome

treatment stage

6-12 weeks time

4-9 months

1 or more years

Kupfer 1991

F33 Recurrent Depressive Disorder

F33 Recurrent depressive disorder F33.0 Recurrent depressive disorder, current episode mild F33.1 Recurrent depressive disorder, current episode moderate F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms F33.4 Recurrent depressive disorder, currently in remission F33.8 Other recurrent depressive disorders F33.9 Recurrent depressive disorder, unspecified

F30 Manic Episode

F30 F30.0 F30.1 F30.2 F30.8 F30.9 Manic episode Hypomania Mania without psychotic symptoms Mania with psychotic symptoms Other manic episodes Manic episode, unspecified

F30.0 Hypomania

Hypomania is characterized by
persistent mild elevation of mood for at least several days increased energy and activity usually marked feelings of well-being and both physical and mental efficiency

Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection. There are no hallucinations or delusions

F30.1 Mania without Psychotic Symptoms

Mania without psychotic symptoms:

last for at least 1 weak mood is elevated out of keeping with individuals circumstances and may vary from carefree joviality to almost uncontrollable excitement elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep normal social inhibition are lost, attention cannot be sustained, and there is often marked distractibility self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressed perceptual disorders may occur the individual may embark on extravagant and impractical schemes, spend money recklessly, or become aggressive, amorous, or factious in inappropriate circumstances.

F30.2 Mania with Psychotic Symptoms

Mania with psychotic symptoms represents a more severe form of mania:

inflated self-esteem and grandiose ideas may develop into delusions, and irritability and suspiciousness into delusions of persecution in severe cases, grandiose or religious delusions of identity or role may be prominent, and flight of ideas and pressure of speech may result in the individual becoming incomprehensible sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of dehydration and self neglect

Mania with:
mood-congruent psychotic symptoms mood-incongruent psychotic symptoms

Manic stupor

F31 Bipolar Affective Disorder

Bipolar affective disorder is characterized by repeated, at least two episodes in which the patients mood and activity levels are significantly disturbed (manic or depressive syndromes, patients who suffer only from repeated episodes of mania are comparatively rare). The first episode may occur at any age from childhood to old age. The frequency of episodes and the pattern of remissions and relapses are both very variable. The lifetime prevalence is between 0,5 an 1 %. Suicidality about 19%. Comorbidity with alcohol and drug abuse The rapid-cycling specifier identifies those patients who have had at least four episodes of a major depressive, manic, or mixed episode during the past 12 months.

F31 Bipolar Affective Disorder

F31 Bipolar affective disorder F31.0 Bipolar affective disorder, current episode hypomanic F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms F31.2 Bipolar affective disorder, current episode manic with psychotic symptoms F31.3 Bipolar affective disorder, current episode mild or moderate depression F31.4 Bipolar affective disorder, current episode severe depression without psychotic symptoms F31.5 Bipolar affective disorder, current episode severe depression with psychotic symptoms F31.6 Bipolar affective disorder, current episode mixed F31.7 Bipolar affective disorder, currently in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified

F34 Persistent Mood (Affective) Disorders

Persistent mood disorders are persistent and usually fluctuating disorders of mood in which individual episodes are not sufficiently severe to warrant being described as hypomanic or even mild depressive episodes. Lasting more than 2 years
Persistent mood (affective) disorders Cyclothymia Dysthymia Other persistent mood (affective) disorders Persistent mood (affective) disorder, unspecified

F34 F34.0 F34.1 F34.8 F34.9

F34.0 Cyclothymia

For cyclothymia persistent instability of mood, involving periods of mild depression and mild elation is typical. This instability usually develops early in adult life and pursues a chronic course, although the mood may be normal and stable for months at a time. The mood swings are usually perceived by the individual as being unrelated to life events.

F34.1 Dysthymia

Dysthymia represents a chronic, milder form of depression which does not fulfill the criteria for recurrent depressive disorder especially in terms of severity. Sufferers usually have periods of days or weeks when they describe themselves as well, but most of the time they feel tired and depressed. It usually begins in adult life and lasts for at least several years, sometimes indefinitely. The lifetime prevalence is approximately 3%, and it is more common in women.

F34.1 Dysthymie

dysthymie: mrn chronick deprese epidemiologie: celoivotn prevalence kolem 3% etiopatogeneze: faktory genetick i vnj lba: jako u depresivn poruchy kognitivn-bahaviorln psychoterapie, antidepresiva

Treatment of Depression

Various antidepressants altering levels of central neurotransmitters are available to treat depression. Their overall effectiveness: 65-70% Mild to moderate depressive episode: SSRIs. Severe depression: antidepressants with broader spectrum of effects, like SNRI or TCA. Patients with insomnia or anorexia may do better with more sedating medication (mirtazapine, trazodon) Patients with lethargy, hypersomnia, weight gain and lower levels of tension and anxiety may prefer the less sedating medications such as bupropion, reboxetin or stimulating SSRIs. IMAOs or RIMA should be tried in refractory patients or patients with atypical depression.

Treatment of Depression

Drug trials should last 4 to 8 weeks. No response within 4 weeks of treatment - the dose should be increased or the patient should be switched to another drug. In partial responders - augmentation strategy; coadministration of lithium carbonate or trijodthyronine. Psychotic patient - adding on neuroleptics. Anxious or agitated patients (also to improve the sleep quality) - benzodiazepine coadministration for a short period of time. Lithium prophylaxis is an option to antidepressants.
Supportive psychotherapy.

Treatment of Depression

First episode of depression - the drug should be continued for another 16-20 weeks after the patient is thought to be well (continuation treatment to prevent recurrence). The medication should be tapered gradually because many patients experience some mild withdrawal effects. Patients with recurrent depression need long-term maintenance therapy to prevent relapses. Electroconvulsive therapy (ECT) is the treatment of choice for some patients with very severe depression, with high potential for suicide or other selfdestroying behaviour and for pregnant women. Other biological methods:
phototherapy (seasonal affective disorder) sleep deprivation repetitive transcranial magnetic stimulation (rTMS).

Treatment of Mania

Mood stabilizers:

Anticonvulsants:
gabapentine topiramate lamotrigine

lithium (0.61.2 mEq/L) carbamazepine (612 mg/L) valproate (50125 mg/L)

Agitated or psychotic patient coadministartion of

ECT

antipsychotics of second generation (olanzapine, risperidone) benzodiazepines (lorazepam, clonazepam)