Mood Disorders

 Learning objectives
 At the end of this lecture students should be able to
identify:
 Signs and symptoms of mood disorders
 Different types disorders
 Management of mood disorders
 Mood Disorders

-Depression
-Mania

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Mood Disorders

Bipolar disorder

Wellness

Dysthymia

Depressive episode

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 Aetiology
Biological Theories for Mood Disorders
Genetic Theories:
-If an individual has a mood disorder, the rates of mood
disorders in his/her relatives is 2-3x greater
-If one twin has a mood disorder, an identical twin is 2-3x
more likely than a fraternal twin to have a mood disorder
-Severe mood disorders have a stronger genetic
contribution
-Bipolar disorder has a stronger genetic loading
-Women have a stronger genetic contribution for
depression than men do
 Neurotransmitter Theories:
-Low levels of serotonin (5HT)
-Permissive hypothesis: when 5HT levels are low, other
neurotransmitters, such as norepinephrine and
dopamine, range more widely & become dysregulated,
contributing to mood irregularities
-Dopamine may play a role in manic episodes
Behavioral Theories of Mood Disorders
Lewinsohn’s Behavioral Model Depression is due to:
-A lack of rewarding, pleasurable experiences reinforcement.
-Stressful, negative life events .
-lack of social skills, continued complaining, & self-
preoccupation.
 Important points

 Depression is projected to be leading cause of disability

worldwide by 2020.
 Depression often goes undiagnosed and untreated
because of :
 stigma
 lack of skilled workforce able to recognize and treat
depression
 Lack of mental health programs outside of psychiatric
hospitals

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 Major Depressive Disorder
 One or more major depressive episodes without a
manic or hypomanic episode
 DSM-5 Diagnosis

 Major Depressive Episode Criteria (cont.)

 Five or more of the following symptoms (at least one of which is
either (1) or (2):
1) Depressed mood
2) Diminished interest in activities
3) Significant weight loss or gain
4) Insomnia or hypersomnia
5) Psychomotor agitation or retardation
6) Fatigue/loss of energy
7) Feelings of worthlessness/inappropriate guilt
8) Diminished ability to think or concentrate/indecisiveness
9) Suicidal ideation or suicide attempt 10
 DSM-5 Diagnosis
 Major Depressive Episode Criteria (cont.)
– Causes marked impairment in occupational functioning or in
usual social activities or relationships
– Not due to substance use or abuse, or a .general medical
condition
– Not better accounted for by Bereavement after the loss of a
loved one, the symptoms persist for longer than 2
months or are characterized by marked functional
impairment, morbid preoccupation with worthlessness,
suicidal ideation, psychotic symptoms, or psychomotor
retardation
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 Onset and course;
 Onset may be sudden or gradual
 Gradual onset often includes weeks-months of
subclinical symptoms
 Acute onset usually follows within 6 months of
a significant stressor
 50% of patients will experience a subsequent
episode
 Risk of recurrence increases with age and
number of previous episodes
 Average number of episodes is 4
 50% recover within 6 months
 Complications and co-morbidity
 15% lifetime suicide risk
 Depressive pseudodementia
 Cognitive deficits related to poor concentration
and energy
 Substance abuse
 Anxiety disorders
 Epidemiology
 Lifetime risk is 10-25% for women, 5-12% for
men
 Point prevalence is 5-10% for women, 2-3% for
men
 Gender distribution is 2:1 W:M
 Epidemiology
 Monozygotic twins show 50-75% concurrence
 25% risk to first-degree relatives
 Types of Depression
Atypical: reversed vegetative symptoms
 Hypersomnia
 Increased appetite or weight gain
 Rejection sensitivity
Melancholia:
 Prominent anhedonia
 Intense vegetative symptoms
 Postpartum: within 4 weeks of delivery of a
child
 Psychotic features: psychosis is present only
during depressive episodes
 Seasonal pattern: depression occurs at specific
times of the year, depression most common in
winter
 Treatment
 Antidepressant medications:
-Selective Serotonin Reuptake Inhibitors
(SSRIs) – usual 1st-line agents

-Tricyclic antidepressants – available at Health

centers
Treatment
 Psychotherapy:
-Cognitive behavioral therapy (CBT)
-Interpersonal therapy (IPT)
Major Depressive Disorder

-Treatment
– Psychotherapy
-65-70% effectiveness in mild-moderate
depression
-Combination of psychotherapy and
medication is more effective than either
treatment alone
Major Depressive Disorder

Treatment
– Electroconvulsive therapy (ECT)
-Indicated for severe depression, lack of
response to other treatments, psychotic
features, high suicide risk, starvation or
dehydration, prior good response, or patient
preference
Treatment
 Electroconvulsive therapy (ECT):
-Relative contraindications are intracranial
mass, dementia, high anesthesia risk
-Primary side effect is memory loss and
confusion (both self-limiting)
 Major Depressive Disorder with Psychotic
Features
 10% of depressed patients develop psychotic
features
 Psychotic symptoms are often (but not always)
congruent with mood
Treatment
 Combination of antidepressant and
antipsychotic medications
-Neither medication works well alone
-50% effective when used together
Treatment
 ECT
-May be appropriate 1st-line treatment
-80-90% effective
 Dysthymic Disorder
 At least 2 years of depressed mood
 2 or more vegetative symptoms
 Does not meet criteria for major depressive
episode for at least the first 2 years
 Lifetime risk is 6%; point prevalence is 3%
 Often co-morbid with episodes of major depression
(“double depression”)
Treatment
 Antidepressant medications
 Psychotherapy (CBT, IPT)
 Bipolar I Disorder

 Bipolar I Disorder (formerly “manic-depression”)

 At least one manic episode with or without a
depressive episode
 DSM-5 Diagnosis
 Manic Episode Criteria
 A distinct period of abnormally and persistently elevated,
expansive, or irritable mood.
 Lasting at least 1 week.
 Three or more (four if the mood is only irritable) of the
following symptoms:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Pressured speech or more talkative than usual
4. Flight of ideas or racing thoughts
5. Distractibility
6. Psychomotor agitation or increase in goal-directed activity
7. Hedonistic (pleasure) interests
 DSM-5 Diagnosis
 Manic Episode Criteria (cont.)
 Causes marked impairment in occupational
functioning in usual social activities or
relationships,
 Has psychotic features
 Not due to substance use or abuse (e.g., drug abuse,
medication, other treatment), or a general medial
condition (e.g., hyperthyroidism).
 A full manic episode emerging during
antidepressant treatment
 Onset and course
 Peak age of onset is in 20s
 Age range for onset is from teens to 60s
 Symptoms tend to progress rapidly (i.e., a few days)
from pleasantly elevated mood at onset to euphoria
to irritability to psychosis.
 Some cases progress to catatonia.
 Episodes are often triggered by physical or
psychosocial stressors
 Episodes are often (~60%) preceded or followed
immediately by a depressive episode
 >90% of patients have recurrent episodes
 70-80% of patients return to full function between
episodes; 20-30% have persistent mood instability
or functional impairment
 Episodes occur every 2-3 years for patients in their
20s, gradually increasing in frequency to 1-2
episodes per year for patients in their 50s
 Complications
 10-15% lifetime suicide risk
 Substance abuse is common
 Epidemiology
 Lifetime prevalence is 1% of the general adult
population
 Gender distribution is male to female1:1
 Monozygotic twins show ~80% concurrence
 25% risk to first-degree relatives
Acute treatment
 Antipsychotic medication – 1st-line treatment
 Mood stabilizers
-Lithium – 1st-line treatment
-Valproic acid – 1st-line treatment
-Other anticonvulsants – carbamazepine,
lamotragine, topiramate
 Avoid antidepressant medications during manic
phase
 Maintenance treatment
– Mood stabilizers (same as above)
 Bipolar II Disorders

 At least one hypomanic episode (no manic episode)

with at least one depressive episode
 Similar onset, course, and complications to bipolar
I disorder
 Lifetime prevalence is 2-3%
 Treatment is the same as major depressive disorder
and bipolar I disorder
Cyclothymic Disorder
 Chronic fluctuating mood not meeting criteria for
manic or major depressive episodes
 Insidious onset in adolescence or young adulthood
followed by chronic course
 50% risk of eventual development of bipolar I or
bipolar II disorder
 Lifetime prevalence is 0.4-1%
 Treatment is the same as major depressive disorder
and bipolar I disorder
 Substance Induced Mood Disorder
 Prominent and persistent mood disturbance
(depressed or elevated) related to intoxication or
withdrawal from a substance (drug of abuse,
medication, toxin)
 Alcohol is most common substance causing
depressed mood
 Amphetamine, cocaine, and steroids (e.g.,
prednisone) are commonly associated with mood
elevation
 May improve spontaneously with detoxification
 Some cases require additional treatment with
antidepressant medications
 Antidepressants are rarely effective if intoxication or
withdrawal continues or recurs
Mood Disorder Due to a General Medical Condition

 Prominent and persistent mood disturbance

(depressed or elevated) related to the direct
physiological effects of an illness