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 2 nd 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

Recovery Relapse Recurrence

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

Depression –Pharmacological –Psychotherapy –Other somatic treatments

Antidepressants

1 st generation –Monoamine Oxidase Inhibitors (MAOIs) –Tricyclic Antidepressants (TCAs) 2 nd –Serotonin reuptake Inhibitors (SSRIs) –Other specifics (Buproprion, Trazodone) 3 rd –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 3 rd 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 2 nd 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