Mood Disorders Dr Joanna Bennett

Mood Disorders Pervasive alterations in emotions that are manifested by depression, mania, or both, and interfere with the person’s ability to function normally

Mood Disorders Major depression: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania and/or depression and normalcy and other symptoms

Some related disorders Seasonal affective disorder (SAD) Postpartum depression Postpartum psychosis

Prevalence International studies Major depression - 3-16% Bipolar disorder 0.3-1.5% Caribbean 4.9% (PAHO 2005) Community prevalence and risk factors for mood disorders are generally unknown

DSM Diagnostic criteria – Major depressive disorder At least one of the following three abnormal moods significantly interferes with the person's life: Depressed mood Loss of interest & pleasure Irritable mood (under 18 yrs) Occurring most of the day, nearly every day, for at least 2 weeks

Diagnostic criteria: Depression At least five of the following symptoms should have been present during the same 2 week depressed period: Depressed or irritable mood Loss of interest & pleasure Appetite/weight disturbance (gain/loss) Sleep disturbances Fatigue/loss of energy Guilt Poor concentration Morbid thoughts of death

Diagnostic criteria: Depression The symptoms are not due to Physical illness, alcohol, medication, or street drug use. Normal bereavement. Bipolar Disorder Delusional or Psychotic Disorders Abnormal depressed mood: Sadness is usually a normal reaction to loss. However, in Major Depressive Disorder, sadness is abnormal because it: Persists continuously for at least 2 weeks. Causes marked functional impairment. Causes disabling physical symptoms (e.g., disturbances in sleep, appetite, weight, energy, and psychomotor activity). Causes disabling psychological symptoms (e.g., apathy, morbid preoccupation with worthlessness, suicidal ideation, or psychotic symptoms). The sadness in this disorder is often described as a depressed, hopeless, discouraged, "down in the dumps," "blah," or empty. This sadness may be denied at first. Many complain of bodily aches and pains, rather than admitting to their true feelings of sadness. Abnormal loss of interest and pleasure mood: The loss of interest and pleasure in this disorder is a reduced capacity to experience pleasure which in its most extreme form is called anhedonia. The resulting lack of motivation can be quite crippling. Abnormal irritable mood: This disorder may present primarily with irritable, rather than depressed or apathetic mood. This is not officially recognized yet for adults, but it is recognized for children and adolescents. Unfortunately, irritable depressed individuals often alienate their loved ones with their cranky mood and constant criticisms.   Major Depressive Disorder causes the following physical symptoms: Abnormal appetite: Most depressed patients experience loss of appetite and weight loss. The opposite, excessive eating and weight gain, occurs in a minority of depressed patients. Changes in weight can be significant. Abnormal sleep: Most depressed patients experience difficulty falling asleep, frequent awakenings during the night or very early morning awakening. The opposite, excessive sleeping, occurs in a minority of depressed patients. Fatigue or loss of energy: Profound fatigue and lack of energy usually is very prominent and disabling. Agitation or slowing: Psychomotor retardation (an actual physical slowing of speech, movement and thinking) or psychomotor agitation (observable pacing and physical restlessness) often are present in severe Major Depressive Disorder. Major Depressive Disorder causes the following cognitive symptoms: Abnormal self-reproach or inappropriate guilt: This disorder usually causes a marked lowering of self-esteem and self-confidence with increased thoughts of pessimism, hopelessness, and helplessness. In the extreme, the person may feel excessively and unreasonably guilty. The "negative thinking" caused by depression can become extremely dangerous as it can eventually lead to extremely self-defeating or suicidal behavior. Abnormal poor concentration or indecisiveness: Poor concentration is often an early symptom of this disorder. The depressed person quickly becomes mentally fatigued when asked to read, study, or solve complicated problems. Marked forgetfulness often accompanies this disorder. As it worsens, this memory loss can be easily mistaken for early senility (dementia). Abnormal morbid thoughts of death (not just fear of dying) or suicide: The symptom most highly correlated with suicidal behavior in depression is hopelessness

Mania: Signs and symptoms Grandiose delusions, inflated sense of self-importance Racing speech, racing thoughts, flight of ideas Impulsiveness, poor judgment, distractibility Reckless behavior In the most severe cases, delusions and hallucinations

Mania: Signs and symptoms Increased physical and mental activity and energy Heightened mood, exaggerated optimism and self-confidence Excessive irritability, aggressive behavior Decreased need for sleep without experiencing fatigue

Types of Bipolar disorder

Diagnostic criteria: Mania Persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) 3 (or more) of the symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

Diagnostic criteria: Mania inflated self-esteem or grandiosity decreased need for sleep more talkative than usual or pressure to keep talking flight of ideas or subjective experience that thoughts are racing distractibility excessive involvement in pleasurable activities

Nursing diagnosis Psychiatrists have formulated clear guidelines for categorizing mental disorders (DSM-1V, ICD-10) – determines interventions Nursing diagnosis provides basis for nursing intervention Systematic collection & integration of data to formulate Nursing Diagnosis The Nurse combines nursing diagnoses and DSM/ICD classifications to develop the treatment plan

Nursing Diagnosis Assessment/psychiatric interview/MSE Example nursing diagnosis Risk for Suicide Ineffective Coping Hopelessness Self-Care Deficit

Aetiology Depression often triggered by stressful life events Contributing factors: Intensity and duration of these events individual’s genetic endowment coping skills social support network - depression and many other mental disorders are broadly described as the product of a complex interaction between biological and psychosocial factors

Biological factors Focus on alterations in brain function Abnormal concentrations of many neurotransmitters and their metabolites in urine, plasma, and cerebrospinal fluid Overactivity of the HPA (hypothalamus-pituitary-adrenal) axis - stress dysfunction in serotonin (5-HT(1A) receptor activity could be due to a hypersecretion of cortisol The results showed that a dysfunction in 5-HT(1A) receptor activity could be due to a hypersecretion of cortisol. Major depression is associated with a dysfunction of the serotonergic activity and the hypothalamic-pituitary-adrenal (HPA) axis

Monoamine Hypothesis Prevailing hypothesis - depression is caused by an absolute or relative deficiency of monoamine transmitters in the brain Evidence that reserpine, a medication for hypertension, caused depression by depleting the brain of both serotonin and the three principal catecholamines (dopamine, norepinephrine, and epinephrine).

Monoamine Hypothesis monoamine hypothesis remains important for treatment purposes. Many currently available pharmacotherapies that relieve depression or mania, or both, enhance monoamine activity. One of the foremost classes of drugs for depression, SSRIs, increase the level of serotonin in the brain.

Psychosocial and Genetic Factors in Depression Social, psychological, and genetic factors act together to predispose to, or protect against, depression. many episodes of depression are associated with some sort of acute or chronic adversity past parental neglect, physical and sexual abuse, and other forms of maltreatment impact on both adult emotional well-being and brain function

Psychosocial and Genetic Factors in Depression early disruption of attachment bonds can lead to enduring problems in developing and maintaining interpersonal relationships and problems with depression and anxiety.

Cognitive factors how individuals view and interpret stressful events contributes to whether or not they become depressed. the impact of a stressor is moderated by the personal meaning of the event or situation Increased vulnerability to depression is linked to cognitive patterns that predispose to distorted interpretations of a stressful event

Genetic factors in depression & Bipolar Susceptibility to a depressive disorder 2-4 times greater among the first-degree relatives of patients with mood disorder The risk among first-degree relatives of people with bipolar disorder 6-8 times greater.

Genetic factors in depression & Bipolar Does not prove a genetic connection. First-degree relatives typically live in the same environment, share similar values and beliefs, and are subject to similar stressors, the vulnerability to depression could be due to nurture rather than nature

Treatment 50 to 70 % of depressed patients who complete treatment respond to either antidepressants or psychotherapies Surveys consistently show that a majority of individuals with depression receive no treatment

Treatment The acute phase - 6 to 8 weeks medication patients should be seen weekly or biweekly for monitoring of symptoms, side effects, dosage adjustments, and support Psychotherapies during the acute phase for depression typically consist of 6 to 20 weekly sessions

Treatment - ECT 60 to 70 % response rate seen with ECT Proposed to be useful with poor response to medication depression is accompanied by potentially uncontrollable suicidal ideas and actions The most common adverse effects are confusion and memory loss for events surrounding the period of ECT treatment.

Management- Maintenance Medication acute phase treatment and at least 6 months of continued treatment TCA’s, SSRI’s, NARIs, MAOIs, St John Wort (Herbal) as effective as antidepressants

Psychosocial interventions : depression NICE Guidelines (2009) Mild depression – psychological Moderate depression – Medication or Psychological Severe depression – CBT & medication

Drug Treatment - Bipolar Lithium – Long-term Anticonvulsants – carbamazipine (not shown to be effective in acute treatment) Antidepressants – SSRIs (inaequate evidence of effectiveness) Antipsychotics – olanzapine, rispiridone (effective short-term)

Psychosocial interventions - Bipolar CBT - group /individual 12-14 sessions < depressive episodes Family therapy psychoeducation, communication skills training, and problem-solving skills training.