Mood Disorders: A Biopsychosocial Approach Katharine Gillis FRCPC Associate Professor Department of Psychiatry University of Ottawa

MOOD DISORDERS Major Depressive Disorder Dysthymic Disorder Bipolar Disorders: I with Mania II with hypomania Cyclothymia

LIFETIMES PREVALENCES Major Depressive Disorder women 10-25 % men 5-12% Dysthymia 6 % Bipolar Disorders type I 0.4-1.6 % type II 0.5%

In the Family Practice Setting 25% of all patients who visit their family physicians will have a diagnosable mental disorder The incidence of major depression is 10% in primary care patients Effective treatment can reduce morbidity and decrease utilization of other health services Medical patients with major depression have a worse prognosis for their medical recovery

Key Concepts in Mood Disorders Mood Disorders are usually EPISODIC Need to inquire about current episode, but also past episodes Past history of episodes that are high or low are the often the key to sorting out the diagnosis Genetics are very important in mood disorders especially Bipolar: ALWAYS ask about family history of mood symptoms or suicide

Key Concepts in Mood Disorders Is there a history of inter episode wellness- better prognosis Are the symptoms chronic Treatment goal is to treat current symptoms but also to try and prevent future episodes of mood symptoms Treatment usually medication based for moderate to severe symptoms plus or minus a specific type of psychotherapy.

How is Major Depression different from just feeling down? Just feeling down should not have “physical symptoms” associated with it Just feeling down should not impair function Just feeling down should not last daily for at least two consecutive weeks or more Untreated an episode of major depression on average lasts 6-12 months

Key Concept for Major Depression For Major Depression must have persistent symptoms of depression or LOSS of INTEREST for at least 2 consecutive weeks Many people with depression do NOT report feeling depressed, but have loss of interest Elderly patients often have new onset of somatic complaints but may deny feeling depressed Need a cluster of four other symptoms besides loss of interest or depression to make the diagnosis

Key Concept for Major Depression Physical symptoms of depression include changes FROM BASELINE in sleep, appetite, energy and physical movements Physical symptoms are often referred to as “vegetative symptoms” The presence of new onset of vegetative symptoms can be a good predictor of response to antidepressant treatment

Physical Symptoms of Major Depression Sleep- change from baseline. Usually too little. All sleep phases can be effected but the classic symptom is early morning awakening. Excessive sleep from baseline is an atypical feature and occurs more in teenagers

Physical Symptoms of Major Depression Appetite-change from baseline usually a decrease Loss of taste for food* Loss of weight Increase in appetite from baseline, especially with carbohydrate craving is an atypical feature and occurs more in teenagers

Physical Symptoms of Major Depression Fatigue- change from baseline Diminished spontaneous movements may be observed and is called psychomotor slowing Physical restlessness may be observed and is called psychomotor agitation

Other Important Symptoms of Major Depression Guilt Impaired concentration Social withdrawal Suicidal thoughts: Safety assessment Panic attacks* Obsessive compulsive symptoms* *Not in DSM-4 criteria

Specifiers for Mood Disorders Specifiers describe the most recent mood episode such as: With Postpartum Onset (within 4 weeks of delivery With Catatonic features With Atypical Features With Rapid Cycling

Specifier- With Seasonal Pattern Only applies to Major Depressive Episode (not manic or hypomanic) Regular temporal relationship between onset of major depressive episode and a particular time of year usually fall or winter Full remission also occurs at regular time of year usually spring (or switch to mania) In the last 2 years two major depressive episodes have occurred as above with no nonseasonal episode of MDE occurring in the two years Seasonal episodes of MDE outweigh nonseasonal episodes in their lifetime

Specifier-With Psychotic Features Psychosis may be present in 10-15% of patients with a Major Depressive Episode Associated with worse prognosis Increase risk of suicide and homicide Important to always screen for psychotic symptoms Has treatment implications- antipsychotic needs to be added to antidepressant. May be an indication to consider ECT.

Epidemiology of Major Depression. Who is at risk? Prevalence for men 5-12%, women 10-25% Mean age of onset is around 40 50% of all patients have onset between the ages of 20 and 50 10% of post partum women are at risk of Major Depressive Episode. Etiology remains unclear, stress vs. hormone

Epidemiology of Major Depression. Who is at risk? No correlation between socioeconomic status and MDE but unemployed are at 3X more risk MDE more common in rural than urban areas Prevalence of mood disorder does not vary among races Loss of a parent before age 11 is a risk Loss of a spouse is a risk

Recurrence Rates in Major Depression After 1 episode 50 % After 2 episodes 75 % After 3 episodes 90 % +

DYSTHYMIA Depressed mood most days for 2 years Depressed symptoms include: appetite disturbance sleep disorder fatigue low self-esteem poor concentration hopelessness indecision

DYSTHYMIA (cont.) Never symptom-free for over 2 months Symptoms cause impaired functioning Antidepressant may or may not be helpful. Psychotherapy may help particularly if many negative cognitions.

Bipolar Disorder Bipolar disorder is characterized by the occurrence of mood episodes, usually with inter-episode wellness. A mood episode can be a major depressive, manic, hypomanic, or mixed episode An episode is demarcated by either switch to an opposite state ( manic to depressive) or 2 months or more of partial or full remission after an episode

Bipolar Type I Prevalence 1% of population men=women Must have at least one Manic Episode Does not require a depressive episode but most patients have depression in their lifetime Most have more depressive than manic episodes Manic episodes are not subtle and usually require hospitalization

Manic Episode Criteria Elevated mood (may be irritable, expansive) persisting for at least one week Need 3 (or 4 if irritable) of the following: Grandiosity Delusions Reduced sleep Talkative Racing thoughts (flight of ideas) Distractibility Psychomotor agitation Poor impulse control, excessive involvement in pleasurable activities

Manic Episode Criteria Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features Symptoms present at least one week Condition not caused by general medical condition or substances

Mixed Episode Criteria Criteria are met for both a manic episode and a major depressive episode (except for duration) nearly every day for 1 week Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features Condition not caused by general medical condition or substances

Bipolar I Average onset for first manic episode is age 32 Most have had 2-3 episodes of depression by history prior to first manic episode Symptoms of acute mania develop over hours to days Untreated manic episode lasts 3 months Untreated depressive episode lasts 6-13 months

Bipolar II Must have hypomanic episode(s) not manic Prevalence 0.5 % population May have major depressive episodes Less functional impairment than Type 1 Often does not require hospitalization If patient looks hypomanic but delusions present then diagnose as manic Did an antidepressant cause the hypomanic symptoms? If so may be Bipolar III.

Hypomanic Episode Elevated, expansive or irritable mood lasting at least 4 days Need 3 (or 4 if irritable) of the following: Grandiosity Delusions Reduced sleep Talkative Racing thoughts (flight of ideas) Distractibility Psychomotor agitation Poor impulse control, excessive involvement in pleasurable activities

Hypomanic Episode Unequivocal change in functioning from baseline The disturbance in mood and the change in functioning is observable by others The episode is NOT severe enough to cause marked impairment in work or social functioning, or to need hospitalization, no psychotic features Symptoms are not caused by a general medical condition or substances

Rapid Cycling Bipolar Disorder Can be applied to Bipolar I and II At least four mood episodes in previous 12 months- depression, mania, hypomania, mixed state Episode demarcated by either switch to opposite state or 2 months of partial or full remission between episodes Rapid cycling diagnosis has treatment implications

CYCLOTHYMIA Numerous periods of depressive symptoms AND hypomania symptoms over 2 years Never symptom free for 2 months No time of Major Depression or Mania Symptoms cause impaired functioning

Common Medical Conditions Associated with Mood Disorders Hypo/hyper thyroidism Cardiovascular disease especially MI CNS- infection, tumour, stroke, head injury, hypoxia Parkinson's, Huntington's, Multiple Sclerosis B12, folate deficiency Chronic pain Sleep Apnea

Drugs Commonly Associated with Mood Disorders Steroids, corticosteroids – depression, mania, anxiety Accutane isoretinoin Oral contraceptives, progesterone Interferon A Evidence for Beta Blockers is weak