Mood Disorders

Bruce Shapiro, M.D.

April 6, 2001

Do psychiatrists have mood swings?

What Determines Mood?What Determines Mood?

Harlow and Spitz

Gross Anatomy

Neuroimaging

Regionalization questions

Synapse

Intracellular activities

Brain mediated environment

History...

Mood Disorders

History The Bible (King Saul, Job) Hippocrates - Humoral theory Arateus - Psychological theory 1800’s - Physical diagnosis 1900’s - Psychological diagnosis 1930’s - Somatic interventions 1940’s - Psychoanalysis 1950’s - Psychopharmacology 1980’s - Biological markers 1990’s - Neuroimaging 2000’s - Herbals and magnetism ...

Hippocrates

Mood Disorders

Famous Sufferers ...

Abraham Lincoln

Winston Churchill

Churchill's Black Dog

"Black Dog”: Churchill's name for his depression

Lord Moran: inborn melancholia Periods of solitude Periods of high energy Highly functional

Ernest Hemingway

Suicide - Familial Aspects

A Quote

“In my last severe depression, I took coca again and a small dose lifted me to the heights in a wonderful fashion”

Sigmund Freud

Freud and Mom or Mom and Freud?

Famous Living Bipolars Robert Boorstin, writer, special assistant to President Clinton Rosemary Clooney, singer Dick Cavett, writer, media personality Kitty Dukakis, former First Lady of Massachusetts Patty Duke (Anna Pearce), actor, writer Connie Francis, actor, musician Shecky Greene, comedian Kristy McNichols, actress Kate Millett, writer Charley Pride, musician Axl Rose, musician Ted Turner, entrepreneur, media giant Jonathon Winters, comedian, actor, writer, artist

Famous Living Unipolars

Buzz Aldrin, astronaut Rona Barrett, entertainment reporter, author Art Buchwald, writer Barbara Bush, former U.S. First Lady Ray Charles, musician Eric Clapton, musician Dick Clark, television personality Leonard Cohen, musician, writer Francis Ford Coppola, director Michael Crichton, writer Kathy Conkrite, writer Sheryl Crow, musician Mike Douglas, media personality Tony Dow, actor, director

>>

Famous Living Unipolars

James Farmer, civil rights activist John Kenneth Galbraith, economist, educator, author Mariette Hartley, actor Anthony Hopkins, actor Robert McFarlane, former US National Security Advisor Joan Rivers, comedienne, talk show host Roseanne, actor, writer, comedienne Rod Steiger, actor William Styron, writer James Taylor, musician Livingston Taylor, musician

Mike Wallace, news anchor Marie Osmond, entertainer

Mood Disorders

Classification andDemographics ...

Mood Disorders (DSM-IV)Depressive Disorders

– Major Depressive Disorder (single/recurrent)– Dythymic Disorder– Depressive Disorder, NOS

Bipolar Disorders– Bipolar I– Bipolar II– Cyclothymic Disorder– Bipolar Disorder, NOS

Mood Disorder due to:– Medical condition– Substance induced

Mood Disorders - DSM IV

Unipolar vs BipolarUnipolar Bipolar

Prev 5% 1%Gender F>M F=MOnset 30’s 20’sSuicide 15% 20%Sleep insom hyperRx unipolar bipolar IIIGenetics lower higher

Epidemiology Lifetime risks:

– Major Depression: 6 %

– All mood disorders: 8 %

Prevalence

– Major Depression: (point prevalence approx 5 -6 %)

• Males: 2.6 - 5.5%

• Females: 6.0 - 11.8 %

– Dysthymia: 3 - 4 %

– In primary care practice:

• Major Depression: 4.8 - 9.2 %

• All depressive disorders: 9 - 20 %

Bipolar Disorder: 1.0 - 2.5 %

5 - 15 % of adult depressions are bipolar

Prevalence of Mood Disorders 20% of the U.S. population reports at least

one depressive symptom in a given month 12% report two or more depressive

symptoms in a year Major Depression: 5% in the previous 30

days, Bipolar Disorder - approximately 1 % of the

population

Increase in cohort post 1940 Younger age of onset

Genetics

Unipolar– Dizygotic: 30%– Monozygotic: 50%– Family history: 25%

Bipolar– Dizygotic: 30%– Monozygotic: 80%– Family history: 50%

Gender differences

Bipolar - no difference

Unipolar - Female > Male– ?genetic– sociocultural– alcoholism/substance abuse

Mood Disorders: Across the Lifespan

Infancy - Spitz and Harlow Childhood - depressive equivalents Adolescence - major onset;

substance abuse Adulthood - major onset Geriatric - multiple symptoms;

pseudodementia; differential medical diagnoses

Predisposing factors Prior mood disorder or moodswings Positive family history Female gender Severe prolonged stress Recent loss

Postpartum period

Medical co-morbidity

Current alcohol/substance abuse

Prognosis

Major Depression recurrence rates: 1 episode: 50 - 60%2 episodes: 70%3 episodes: 90%

Untreated episode: 6-12 months 20-30 % chronicity Episode length and frequency: shorter

episodes with increasing frequency Treatment yields good results

Mood Disorders

Clinical Syndromes ...

Hypomania:What does it feel like?“At first when I'm high, it's tremendous...ideas

are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do

anything...but, somewhere this changes”.

Mania:What does it feel like?“The fast ideas become too fast and there

are far too many...overwhelming confusion replaces clarity...you stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped”.

Clinical Mania A sustained period of behavior that is different

from usual Increased energy, activity, restlessness, Racing thoughts and rapid talking Excessive "high" or euphoric feelings Extreme irritability and distractibility Decreased need for sleep Unrealistic beliefs in one's abilities and powers Uncharacteristically poor judgment

>>

Clinical Mania Reckless behavior Increased suspiciousness/paranoid ideation Increased sexual drive Abuse of drugs, particularly cocaine, alcohol, and

sleeping medications

Flight of ideas Provocative, intrusive, or aggressive behavior Possibly delusions (paranoid/grandiose/religious) Possibly hallucinations

Denial that anything is wrong

Cycle Length

Bipolar: Frequency of Recurrence

Hypomania Inflated self-esteem

Decreased need for sleep

More talkative than usual

Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Increased activity

No major life disruption

No need for hospitalization

No psychotic symptoms

Cyclothymia

Alternating hypomania and

non-major depression

At least 2 years in duration

Depression:What does it feel like?“I doubt completely my ability to do anything

well. It seems as though my mind has slowed down and burned out to the point of being virtually useless....[I am] haunt[ed]...with the total, the desperate hopelessness of it all... Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?”

Sadness vs Clinical Depression

Intensity Duration Neurovegetative changes Self esteem changes Normal Grief vs. Depressive Illness

Depressive Disorders - DSM - IV

Major Depressive Disorder (296.xx)

Dysthymic Disorder (300.4) Depressive Disorder NOS (311) Mood Disorder due to general

medical condition (293.83) Substance-Induced mood

disorder (293.83)

Clinical Depression Loss of the ability to experience pleasure Unexplained or prolonged sadness or

crying spells Significant changes in appetite and sleep

patterns Diurnal variation of mood Irritability, anger, worry, agitation,

anxiety Pessimism, indifference A sense of hoplessness/helplessness

Clinical Depression Loss of energy, persistent lethargy,

pathological fatigue Feelings of guilt, worthlessness Inability to concentrate,

indecisiveness Social withdrawal Difficulty with personal hygiene Unexplained aches and pains May have delusions or hallucinations Recurring thoughts of death or suicide

Other Specifiers

Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset

Physical Symptom Indicators

Fatigue Pain Sleep disturbances GI disorders (IBS)

– unexplained by medical testing

Atypical Presentations

Anxiety/panic symptoms Irritability Hysterical symptoms Hypochondriacal symptoms Unexplained pain syndromes Substance abuse presentations “Personality disorder”

Dysthymia

This disorder is characterized by a chronic state of depression, exhibited by a depressed mood on most days for at least 2 years. (1 year in children and adolescents).

There are no psychotic symptoms .

Dysthymia: symptoms and duration

poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self-esteem poor concentration or difficulty

making decisions feelings of hopelessness

Dysthymic individuals must not have gone for more than 2 months

without experiencing two or more of these symptoms

Mood Disorders

Suicide ...

Suicide Rates in Mood Disorders

Unipolar: 15 %

Bipolar: 20 %

Suicide Risk Factors

Clinical depression Suicidal ideation Self oriented (non-manipulative) Available lethal method Male>Female White>black Elderly Loss with alcohol/substance abuse

Suicide Rates

Suicide - Clusters

Mood Disorders

CausesandTreatments ...

Psychological Models

Psychoanalytic Interpersonal Cognitive Behavioral/learned

helplessness

Treatment: Psychological Individual Psychotherapy

– Psychodynamic/Psychoanalytic– Cognitive– Interpersonal– Supportive

Group Therapy Couples Therapy Family Therapy

Biological Models

Genetic Neurotransmitter dysfunction Neuroendocrine dysfunction Chronobiological Sensitization/Kindling

Serotonergic pathways

Neurotransmission

Neurons

Basic Synapse

Serotonin Synapse

Reuptake pump

Synaptic Interactions

Synaptic Transmission

Biological Markers in Major Depression

DST

TRH/TSH

Shortened REM latency

Treatment: Biological

Antidepressants Antipsychotics (typical, atypical) Mood stabilizers (thymoleptics) Augmentation strategies Herbal Phototherapy ECT rTMS

Mood Stabilizing Medications

Lithium carbonate/citrate Tegretol (carbamazepine) Depakote (valproic acid) Neurontin (gabapentin) Lamictal (lamotrigine) Klonopin (clonazepam) Zyprexa (olanzapine)

Antidepressant Medication Antidepressant medications are non-

addictive. Another antidepressant can be tried

should the first have unacceptable side-effects.

Antidepressants take time to work Physical symptoms are more likely to

respond before psychological symptoms Undulating improvement

Antidepressant medications

TCA’s (imipramine, nortriptyline, desopramine) MAOI’s (phenelzine, tranylcypromine, meclobemide) SSRI’s (fluoxetine, sertraline, paroxetine, fluvoxamine,

citalopram) SNRI’s (venlafaxine) CRI’s (buprorion) Alpha2 adrenergic antagonists (mirtazapine) Serotonin2A antagonists and serotonin reuptake

inhibitors (trazodone, nefazodone) Modified amino acids (SAMe) Psychostimulants Augmentation strategies (Li, T3, buspirone, anxiolytics )

Electroconvulsive Therapy (ECT)

History Indications Efficacy Adverse effects Safety

rTMS

Integrative Treatments

Nature AND Nurture In major syndromes: combinations

of medication and psychotherapy Treat the individual Never give up