Mood Disorders
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This document provides an overview of mood disorders, including bipolar disorder and major depressive disorder. It discusses the classification, symptoms, diagnostic criteria, epidemiology, pathophysiology, etiology, presentation, differential diagnoses, screening tests, and management of mood disorders. The learning objectives are to describe mood and affect, classify mood disorders, identify the sources of mood disorders, determine the diagnostic criteria for depression, and describe proper management of depressive disorders.
Mood Disorders
- 1. Mood Disorders 1 LEARNING OBJECTIVES After attending this presentation you will be able to: 1. Describe the term mood and affect. 2. Classify mood disorders. 3. Identify the sources of mood disorders. 4. Determine the main diagnostic criteria for depression. 5. Describe the proper management for depressive disorders.
- 2. Outlines Background Epidemiology Pathophysiology Etiology Bipolar affective disorder Dysthymic Presentation Differential Diagnoses Screening Tests Management Prognosis Conclusion References 2
- 3. Mood and affect It can be useful to conceptualize the relationship between emotional affect and mood as being similar to that between the weather (affect) and the season (mood). Affect an immediately expressed and observed emotion. A feeling state becomes an affect when it is observable, for example, as overall demeanor or tone and modulation of voice. Affect is to be distinguished from mood, which refers to a pervasive and sustained emotion. Affect refers for the expressions of emotion objectively, while mood refers to innate emotional experience over a more prolonged period of time. Mood and Affective disorders can be classified as: 1. Bipolar Affective Disorders 2. Depressive Disorders 3. Depression in association with medical illness or alcohol and substance abuse 3
- 4. Bipolar affective disorder Bipolar affective disorder, or manic-depressive illness (MDI), is a common, severe, and persistent mental illness. Manic episodes are feature at least 1 week of profound mood disturbance, characterized by elation, irritability, or expansiveness. At least 3 of the following symptoms must also be present : Grandiosity Diminished need for sleep Excessive talking or pressured speech Racing thoughts or flight of ideas Clear evidence of distractibility Increased level of goal-focused activity at home, at work, or sexually Excessive pleasurable activities, often with painful consequences 4
- 5. Bipolar affective disorder (cont.) Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4 consecutive days’ duration. At least 3 of the following symptoms are also present : Grandiosity or inflated self-esteem Diminished need for sleep Pressured speech Racing thoughts or flight of ideas Clear evidence of distractibility Increased level of goal-focused activity at home, at work, or sexually Engaging in activities with a high potential for painful consequences 5
- 6. Depressive Disorders The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders as disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, and depressive disorder due to another medical condition. This article focuses on major depressive disorder in adults 6
- 7. Epidemiology United States statistics The lifetime incidence of major depressive disorder in the United States is 20% in women and 12% in men. In 2010, the Centers for Disease Control and Prevention (CDC) released a report estimating the prevalence of current depression in adults from 2006-2008. Of 235,067 adults, 9% met the criteria for current depression, including 3.4% who met the criteria for major depression. 7
- 8. Pathophysiology The underlying pathophysiology of major depressive disorder has not been clearly defined. Current evidence points to a complex interaction between neurotransmitter availability and receptor regulation and sensitivity underlying the affective symptoms. Clinical and preclinical trials suggest a disturbance in central nervous system serotonin (5-HT) activity as an important factor. Other neurotransmitters implicated include norepinephrine (NE), dopamine (DA), glutamate, and brain-derived neurotrophic factor (BDNF). 8
- 9. Pathophysiology (cont.) Endocrine changes in depression are evident across the life span, but some are unique to aging. Women with a previous history of depression are at higher risk of developing depression during menopause, although estrogen replacement does not relieve depression; low testosterone levels have been associated with depression in older men. 9
- 10. Etiology The specific cause of major depressive disorder is not known. Major depressive disorder appears to be a multifactorial and heterogeneous group of disorders involving both genetic and environmental factors. Genetics Genetic factors play an important role in the development of major depression. Evidence from twin studies suggests that major depression has a concordance of 40-50%. Two susceptibility loci have been identified in which no specific gene of interest has been definitively identified. The MDD1 locus is located at 12q22-q23.2 and is most strongly linked to major depression in males. The MDD2 locus is located at 15q25.2-q26.2 and has been associated with early onset or recurrent episodes of depression. Stressors Chronic pain, medical illness, and psychosocial stress can also play a role in major depressive disorder. 10
- 11. Presentation History Familial, social, and environmental factors Dysphoric mood Psychosis Physical Examination a complete mental health evaluation should always include a medical evaluation to rule out organic conditions that might imitate a depressive disorder. Most of these fall into the following major general categories: Infection Medication Endocrine disorder Tumor Neurologic disorder Appearance and affect Speech 11
- 12. Dysthymic Dysthymic disorder is a depressive mood disorder characterized by a chronic course and an insidious onset. By definition, this condition has a duration of at least 2 years in adults and 1 year in adolescents. It is manifested as a depressed mood, or irritable mood in children, for most of the day, occurring more days than not, and is accompanied by at least 2 of the following symptoms : 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration and/or difficulty making decisions 6. Feelings of hopelessness The DSM-IV-TR categorizes dysthymia according to course specifiers. These include: 1. early onset if symptoms began before age 21 years, 2. late onset if symptoms began at age 21 years or later, and 3. dysthymia with atypical features if symptoms include increased appetite or weight gain, hypersomnia, a feeling of leaden paralysis, and extreme sensitivity to rejection 12
- 13. Major Depressive Disorder The specific DSM-5 criteria for major depressive disorder are outlined below. At least 5 of the following symptoms have to have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood) : 1. Depressed mood: For children and adolescents, this can also be an irritable mood 2. Diminished interest or loss of pleasure in almost all activities (anhedonia) 3. Significant weight change or appetite disturbance: For children, this can be failure to achieve expected weight gain 4. Sleep disturbance (insomnia or hypersomnia) 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness 8. Diminished ability to think or concentrate; indecisiveness 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide The symptoms cause significant distress or impairment in social, occupational or other important areas of functioning. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders There has never been a manic episode or a hypomanic episode. 13
- 14. Postpartum Depression Depression in the postpartum period is a common and potentially very serious problem; up to 85% of women can develop mood disturbances during this period. For most women, symptoms are transient and relatively mild (ie, “postpartum blues”); however, 10-15% of women experience a more disabling and persistent form of depression, with an onset later than the postpartum blues, and 0.1-0.2% of women experience postpartum psychosis. Seasonal Affective Disorder About 70% of depressed people feel worse during the winter and better during the summer. To meet the DSM-5 diagnostic criteria for major depressive disorder with seasonal pattern, depression should be present only at a specific time of year (e.g., in the fall or winter) and full remission occurs at a characteristic time of year (e.g., spring). Patients with seasonal affective disorder are more likely to report atypical symptoms, such as hypersomnia, increased appetite, and a craving for carbohydrates. 14
- 15. Differential Diagnoses Adjustment Disorders Anemia Chronic Fatigue Syndrome Dissociative Disorders Hypochondriasis Hypoglycemia Hypopituitarism (Panhypopituitarism) Schizoaffective Disorder Schizophrenia Somatoform Disorders 15
- 16. Screening Tests The following 2-question test addresses depressed mood and anhedonia: 1. During the past month, have you been bothered by feeling down, depressed, or hopeless? 2. During the past month, have you been bothered by little interest or pleasure in doing things? Longer self-report screening instruments for depression include the following: PHQ-9 – The 9-item depression scale of the Patient Health Questionnaire; each item is scored 0 to 3, providing a 0 to 27 severity score Beck Depression Inventory (BDI) – A 21-question symptom-rating scale BDI for primary care – A 7-question scale adapted from the BDI Zung Self-Rating Depression Scale – A 20-item survey Center for Epidemiologic Studies-Depression Scale (CES-D) – A 20-item instrument that allows patients to evaluate their feelings, behavior, and outlook from the previous week 16
- 17. Management Pharmacologic Therapy for Depression Psychotherapy Electroconvulsive therapy Stimulation techniques Drugs used for treatment of depression include the following: Selective serotonin reuptake inhibitors (SSRIs) Serotonin/norepinephrine reuptake inhibitors (SNRIs) Atypical antidepressants Tricyclic antidepressants (TCAs) Monoamine oxidase inhibitors (MAOIs) 17
- 18. Serotonin/norepinephrine reuptake inhibitors SNRIs, which include: 1. venlafaxine, 2. desvenlafaxine, 3. duloxetine, and 4. levomilnacipran can be used as first-line agents, particularly in patients with significant fatigue or pain syndromes associated with the episode of depression. SNRIs also have an important role as second-line agents in patients who have not responded to SSRIs. The safety, tolerability, and side-effect profiles of SNRIs include those of the SSRIs, as well as noradrenergic side effects, such as hypertension. In July 2013, the FDA approved the newest SNRI levomilnacipram which is available as a once-daily sustained-release formulation. It has greater potency for norepinephrine reuptake inhibition than for serotonin reuptake inhibition without directly affecting the uptake of dopamine or other neurotransmitters. 18
- 19. Psychotherapy Types of psychotherapy that have been used for the treatment of major depressive disorder, especially in the pediatric population, include the following: Behavior therapy Cognitive-behavioral therapy Family therapy Group psychotherapy Interpersonal psychotherapy Interpersonal therapy Psychodynamic psychotherapy Supportive psychotherapy In mild cases, psychosocial interventions are often recommended as first-line treatments. 19
- 20. Prognosis Major depressive disorder has significant potential morbidity and mortality, contributing as it does to suicide, incidence and adverse outcomes of medical illness, disruption in interpersonal relationships, substance abuse, and lost work time. With appropriate treatment, 70-80% of individuals with major depressive disorder can achieve a significant reduction in symptoms, although as many as 50% of patients may not respond to the initial treatment trial. Suicide According to Centers for Disease Control and Prevention (CDC) data , suicide was the 10th leading cause of death in the United States in 2009, accounting for 36,909 deaths; it was the second leading cause of death in people 25-34 years of age, the third leading cause in people aged 10-24 years, and the fourth leading cause at ages 35-54. 20
- 21. Conclusion The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). classifies the depressive disorders as disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, and depressive disorder due to another medical condition. The differential diagnosis for depression includes other psychiatric disorders, CNS diseases, endocrine disorders, drug-related conditions, infectious and inflammatory diseases, and sleep- related disorders. Depression screening tests can be used to screen for depression and bipolar disorder. The most widely used is the Patient Health Questionnaire-9 (PHQ-9). It is important to understand that the results obtained from the use of any depression rating scales are imperfect in any population, especially the geriatric population. All antidepressants approved by the FDA for use in major depression have proven to be effective, although predicting what an individual patient’s response to a particular agent will be is difficult. 21
- 22. References Oxford Handbook of Psychiatry, 1st Edition www.glaxowellcome.com http://www.minddisorders.com/A-Br/Affect.html#ixzz3TIZWYTbr http://www.medicalobserver.com Lecture-note 22