2. Mood Disorders Predominant symptom is the dysregulation of mood or emotion High risk of suicide Can occur throughout the lifespan Types of Mood disorders Major Depression Subcategories of Depression Bipolar Disorder (formerly called Manic-Depression)

3. Co-Morbidity of Mood Disorders Medical diseases may contribute to depression: Myocardial infarct, Stroke, All neurological disorders, e.g. Parkinson’s, Alzheimer’s, Endocrine Disorders e.g. Diabetes, Hypothyroidism, Pregnancy and Post- partum period Some medications can cause depression or mania as side effects, e.g. Prednisone, Chantix Drugs that deplete catecholamines cause depression Dopamine Serotonin Norepinephrine

4. Positive Emission Tomography (PET) Scans Altered blood flow in the brains of depressed Persons Prefrontal cerebral cortex and the limbic system have look different in depressed and non- depressed persons

5. Symptoms of Major Depression Emotional Symptoms Anhedonia – loss of interest or pleasure in activities Depressed mood. Also can be sad, empty, numb or irritable Helplessness, Hopelessness Cognitive Symptoms Diminished ability to think or make decisions Decreased concentration Recurrent thoughts of death, disease, illness, suicide Focus on self-worthlessness and guilt Can have nihilistic delusions, or delusions of persecution or punishment

6. Symptoms of Major Depression Behavioral Symptoms Significant appetite changes – weight loss or gain Insomnia or hypersomnia (mid-nocturnal waking) Psychomotor agitation – restless, pacing Psychomotor retardation – lethargy, slowed down movements and body Fatigue, listlessness, apathy, frequent napping Social Symptoms Withdrawal from others Social isolation

7. Bipolar Disorder Diagnosed when a person has both Depression and Manic episodes

8. Bipolar Disorder Depressed episodes of bipolar disorder look just like Major Depression Diagnosis is based on the occurrence of manic episodes Cyclical in nature Generally occur right before or right after a depressive episode Mania is defined as an abnormal and persistently elevated, expansive or irritable mood for at least 1 week

9. Bipolar Disorder - Mania In addition to expansive or elevated mood, at least 3 of the following must also be present: Inflated self-esteem (Grandiosity) Decreased need for sleep More than usual talkativeness Racing thoughts Distractibility Increase in goal-directed activity Excessive involvement in pleasurable activities Risk-taking behaviors Sexually inappropriate behaviors

10. Hypomania Hypomanic episodes are not severe enough to cause severe impairment in social/occupational functioning Hypomania is very pleasant and productive - HOWEVER – At any point, hypomania may progress into full blown mania As mania progresses, judgment declines. The client may fail to recognize worsening symptoms

11. Treatment of Mood Disorders Therapy: Cognitive-behavioral Approaches Electroconvulsive therapy Transcranial Magnetic Stimulation Vagal Nerve Stimulation Phototherapy Medications: Antidepressants Mood stabilizers Antipsychotics if needed Adjunctive treatment for sleep, anxiety Diet & Nutrition L-Methylfolate

12. Medications for Depression Herbal Therapies St. John’s Wort – very mild monoamine oxidase inhibitor. Overall effect is to increase monoamines (norepinephrine, serotonin, dopamine) Prescription Drugs – Five Categories Serotonin Reuptake Inhibitors (SSRIs) Monoamine Oxidase Inhibitors (MAOIs)* Tricyclic Antidepressants (TCAs)* Serotonin + Norepinephrine Reuptake Inhibitors (SNRIs)* Miscellaneous * *Will be covered in future classes

13. Serotonin Reuptake Inhibitors (SSRIs) The most commonly prescribed antidepressants Blocking the reuptake of serotonin at the nerve synapse Also used for treating anxiety disorders and premenstrual dysphoric disorder (PMS) SSRI Common Side Effects: GI Upset Headaches or dizziness Insomnia Sexual dysfunction Occasionally sleepiness

14. SSRI Medications Prototype: Fluoxetine (Prozac) Other SSRIs: Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro)

15. Serotonin Withdrawal Rapid withdrawal of serotonin from the brain can result in uncomfortable (but not dangerous) withdrawal symptoms: Dizziness Flu-like symptoms The potent, shorter half-life medications have more withdrawal risk while the longer half-life medications have almost none.

16. Adverse Event – Serotonin Syndrome This is a reaction that can happen with high dosages of SSRI’s or when SSRI’s are combined with some other drugs e.g. tramadol (Ultram) or triptans used in migraine headache treatment. Symptoms: Agitation or restlessnessDiarrhea Fast heart beatHallucinations Increased body temperatureNausea/Vomiting Loss of coordinationOveractive reflexes Rapid changes in blood pressure Confusion

17. Mood Stabilizers Drugs for Bipolar disorder are mood stabilizers Very few drugs are approved for children yet all are in use Side Effects vary greatly based on categories Different categories may be combined in treatment resistant patients Categories of Mood Stabilizers Antiepileptics Lithium* Atypical Antipsychotics* Benzodiazepines* *Will be covered in future classes

18. Mood Stabilizers - AntiEpileptics These drugs seem to work by: Decreasing the neurotransmitter glutamate (excitability) Increasing the neurotransmitter GABA (inhibitory) This activity suppresses seizures, reduces mania and can prevent migraine headaches.

19. Mood Stabilizers - AntiEpileptics FDA Approved drugs for Bipolar Disorder: PROTOTYPE: Valproic acid (Depakote) Others: Carbamazepine (Tegretol) Lamotrigine (Lamictal) Side & Adverse effects vary based on the drug but are commonly: GI upset Weight gain Sleepiness Changes in CBCs – check CBC Liver impairment – check liver enzymes ALT/AST

20. In-class Case Study We will next be watching a video of a person with depression. Please answer the following questions during the video then we will discuss them afterwards. 1. What are the client’s symptoms of depression? 2. What are her psychosocial stressors? 3. How are her clients symptoms interfering with her daily functioning? 4. How would you assess her safety risk? 5. What are protective (helpful) factors for this person?

21. Psychiatric Interview: Depressed Client https://www.youtube.com/watch?v=4YhpWZCdiZc