Mood Disorders

Archetypes

• Depression– Major Depression

• Mania– Bipolar Disorder (Manic-Depression)

Phenomenology: The Mental Status Exam

• General Appearance

• Emotional

• Thought

• Cognition

• Judgment and Insight

• Reliability

General Appearance

• Depression

• Mania

Emotions: Depression

• Mood– Dysphoric– Irritable, angry– Apathetic

• Affect– Blunted, sad, constricted

Emotions: Mania

• Mood– Euphoric– Irritable

• Affect– Heightened, dramatic, labile

Thought: Depression

• Process– Slowed processing

• Thought blocking

• Content• Everything’s awful

• Guilty, self-deprecating

• Delusional

Thought: Mania

• Process– Rapid– Pressured speech– Loosening of Associations

• Content – Grandiose– Delusions

Cognition

• Depression– Poor attention

– Registration

– Effort

– “Pseudodementia”

• Mania– Distractible

– Concentration

– May seem brighter, more clever

Insight and Judgment

• Depression– Unrealistically negative

• Mania– Unrealistically positive– Or just plain bad

Diagnosis and Criteria

• Episodes Versus Disorders

Episodes

• Major depressive

• Manic

• Mixed

• Hypomanic

Major Depressive Episode

• Time– 2 weeks

• Change– From previous functioning

• Symptoms– 5 or more– 1 has to be depressed mood or anhedonia

• Global Criteria

Symptoms of Major Depressive Episode

• “Sig E Caps”– Sleep– Interest– Guilt– Energy– Concentration– Appetite– Psychomotor retardation– Suicide

• 5 or more

Manic Episode

• Time– 1 week

• Symptom list– 3 or more

• Global Criteria

Symptoms of Manic Episode

– Grandiosity– Decreased need for sleep– Pressured Speech– Flight of Ideas– Distractibility– Increased Activity/Agitation– Risky Activities

• 3 or more

The Disorders

Major Depressive Disorder

• “Classic Depression”• Major Depressive

Episode• Rule outs

– Some other disorder

– History of mania/hypomania

Bipolar Disorder I

• Classic “Manic-Depression”

• At least one– Manic or,– Mixed episode

Epidemiology

• Depression– 5-7%

– 2:1 ♀:♂

– $53 billion/year in US

– World: most costly (developed)

Epidemiology

• Bipolar Disorders– 1%

– ~1:1 ♀:♂

Etiology and Pathophysiology

Genetics

• Family studies– Higher rates– Breed true?

• Twin Studies– Mono:Di ~4:1

• Linkage studies– Numerous (? Consistency)– Recent: Zubenko, Am J Genetics

Social/Environmental

• Response to Loss– ex. Animal models

• Other stress– Ex. Learned helplessness

• What is role of social stress?– Ex. Nemeroff et al.

Neurotransmission

• Neurochemical hypotheses– Catecholamine hypothesis

• Norepinephrine– Ex. Axelrod

– Depletions models

• Serotonin

– Refinements• Imbalances

• Receptors

• 2nd messengers

Neuroimaging

• Stroke data– Dominant frontal

– Basal ganglia

• Fx Imaging

Other Physiological Findings

• Neurophysiology– Circadian rhythms and sleep

• Neuroendocrine– HPA axis

• DST

Differential Diagnosis

“We’re not living happily ever after any more”

Differential Diagnosis

• Psychiatric Disorders

• Medical Disorders

• Substance Induced

• Reactive disorders– Adjustment disorders– Normal reactions

Comorbidity

• Anxiety disorders• Substance abuse• Psychotic disorders• Personality disorders• Depression in the

medically ill.

Comorbidity

Course and Prognosis of Mood Disorders

Course and Prognosis of Mood Disorders

• Recovery

• Relapse

• Recurrence

01020

30405060708090

0.5 1 2 4 5

Recovery

Predictors

• # Episodes• Length of episodes• Symptoms

– # and type

• Comorbidity

Risk of Suicide

• Depression– 10-15% severe (hosp) pts

“It is unfortunate that I didn’t get

your care earlier, Mrs. Perkins.”

Treatment

Treatment

• Depression– Pharmacological– Psychotherapy– Other somatic treatments

Antidepressants

Antidepressants

• 1st generation– Monoamine Oxidase Inhibitors (MAOIs)– Tricyclic Antidepressants (TCAs)

• 2nd

– Serotonin reuptake Inhibitors (SSRIs)– Other specifics (Buproprion, Trazodone)

• 3rd

– Venlafaxine, Mirtazapine, Nefazodone

Mechanisms of action

• Monoamine Action– Increase

• Norepinephrine

• Serotonin

– Various mechanisms• Inhibition of catabolism (MAOIs)

• Reuptake inhibition (TCAs, SSRIs, Venlafaxine)

• Direct effects (agonism/antagonism) (some 3rd gen)

Side effects

• Predicable– Anticholinergic

– Antihistaminic

– Serotonergic

• Idiopathic

Choice of antidepressant

• Best?• Fastest?• Predictors of response

– Past history

– Family history

• Major difference– Side effects

Treatment failure

• Inadequate dose

• Inadequate time

• Nonadherence

Strategies for failure

• Choices– Increase dose?– Augment?– New drug?

Lithium

Thyroid hormone

Stimulants

Atypical Antipsychotics

2nd Antidepressant

Long term treatment

• Recurrent depression (3+)

• Chronic depression (2 years)

• Double depression

• Others

Psychotherapy

• Cognitive behavioral therapy

• Interpersonal therapy• Others

Medications versus therapy

• Severe depression

• Moderate depression

• Combination treatment

• Prevention

Other treatments

• ECT

• TMH

• Vagal nerve stimulation

ECT

• Maybe the best.• Medication failure• Real serious

depression• Time sensitive• So why don’t we give

everybody ECT?

Bipolar Disorder

• Lithium

• Antipsychotics

• Anticonvulsants

Lithium

• First line

• Best for mania

• 2 weeks for effect

• Therapeutic index

• Side effects

• Acute and preventive

Anticonvulsants

• Sodium Valproate• Carbamazapine• Lamotrigine• Gabapentin• Antimanic• Antidepressant• Prevention• Side effects

Antipsychotics

• Atypical (olanzapine)

• Classic

• May be as effective

• Early and late effect

Sedatives

• Acute use

Other Diagnoses

Other Episodes

• Mixed

• Hypomanic

Other Mood Disorders

• Dysthymic Disorder

• Cyclothymic Disorder

• Bipolar II

• Due to a generalized medical condition

• Substance Induced

• NOS