1. Mood Disorders

2. Archetypes Depression –Major Depression Mania –Bipolar Disorder (Manic-Depression)

5. Phenomenology: The Mental Status Exam General Appearance Emotional Thought Cognition Judgment and Insight Reliability

6. General Appearance Depression Mania

7. Emotions: Depression Mood –Dysphoric –Irritable, angry –Apathetic Affect –Blunted, sad, constricted

8. Emotions: Mania Mood –Euphoric –Irritable Affect –Heightened, dramatic, labile

9. Thought: Depression Process –Slowed processing Thought blocking Content Everything’s awful Guilty, self-deprecating Delusional

10. Thought: Mania Process –Rapid –Pressured speech –Loosening of Associations Content –Grandiose –Delusions

11. Cognition Depression –Poor attention –Registration –Effort –“Pseudodementia” Mania –Distractible –Concentration –May seem brighter, more clever

12. Insight and Judgment Depression –Unrealistically negative Mania –Unrealistically positive –Or just plain bad

15. Diagnosis and Criteria Episodes Versus Disorders

16. Episodes Major depressive Manic Mixed Hypomanic

17. Major Depressive Episode Time –2 weeks Change –From previous functioning Symptoms –5 or more –1 has to be depressed mood or anhedonia Global Criteria

18. Symptoms of Major Depressive Episode “Sig E Caps” –Sleep –Interest –Guilt –Energy –Concentration –Appetite –Psychomotor retardation –Suicide 5 or more

19. Manic Episode Time –1 week Symptom list –3 or more Global Criteria

20. Symptoms of Manic Episode –Grandiosity –Decreased need for sleep –Pressured Speech –Flight of Ideas –Distractibility –Increased Activity/Agitation –Risky Activities 3 or more

21. The Disorders

22. Major Depressive Disorder “Classic Depression” Major Depressive Episode Rule outs –Some other disorder –History of mania/hypomania

23. Bipolar Disorder I Classic “Manic-Depression” At least one –Manic or, –Mixed episode

24. Epidemiology Depression –5-7% –2:1 ♀:♂ –$53 billion/year in US –World: most costly (developed)

25. Epidemiology Bipolar Disorders –1% –~1:1 ♀:♂

26. Etiology and Pathophysiology

27. Genetics Family studies –Higher rates –Breed true? Twin Studies –Mono:Di ~4:1 Linkage studies –Numerous (? Consistency) –Recent: Zubenko, Am J Genetics

28. Social/Environmental Response to Loss –ex. Animal models Other stress –Ex. Learned helplessness What is role of social stress? –Ex. Nemeroff et al.

29. Neurotransmission Neurochemical hypotheses –Catecholamine hypothesis Norepinephrine –Ex. Axelrod –Depletions models Serotonin –Refinements Imbalances Receptors 2 nd messengers

30. Neuroimaging Stroke data –Dominant frontal –Basal ganglia Fx Imaging

31. Other Physiological Findings Neurophysiology –Circadian rhythms and sleep Neuroendocrine –HPA axis DST

32. Differential Diagnosis “We’re not living happily ever after any more”

33. Differential Diagnosis Psychiatric Disorders Medical Disorders Substance Induced Reactive disorders –Adjustment disorders –Normal reactions

35. Comorbidity Anxiety disorders Substance abuse Psychotic disorders Personality disorders Depression in the medically ill.

36. Comorbidity

37. Course and Prognosis of Mood Disorders

38. Recovery Relapse Recurrence

42. Predictors # Episodes Length of episodes Symptoms –# and type Comorbidity

43. Risk of Suicide Depression –10-15% severe (hosp) pts

44. “It is unfortunate that I didn’t get your care earlier, Mrs. Perkins.” Treatment

45. Depression –Pharmacological –Psychotherapy –Other somatic treatments

46. Antidepressants

47. 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

48. 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)

49. Side effects Predicable –Anticholinergic –Antihistaminic –Serotonergic Idiopathic

50. Choice of antidepressant Best? Fastest? Predictors of response –Past history –Family history Major difference –Side effects

51. Treatment failure Inadequate dose Inadequate time Nonadherence

53. Strategies for failure Choices –Increase dose? –Augment? –New drug? Lithium Thyroid hormone Stimulants Atypical Antipsychotics 2 nd Antidepressant

54. Long term treatment Recurrent depression (3+) Chronic depression (2 years) Double depression Others

55. Psychotherapy Cognitive behavioral therapy Interpersonal therapy Others

56. Medications versus therapy Severe depression Moderate depression Combination treatment Prevention

57. Other treatments ECT TMH Vagal nerve stimulation

58. ECT Maybe the best. Medication failure Real serious depression Time sensitive So why don’t we give everybody ECT?

59. Bipolar Disorder Lithium Antipsychotics Anticonvulsants

60. Lithium First line Best for mania 2 weeks for effect Therapeutic index Side effects Acute and preventive

61. Anticonvulsants Sodium Valproate Carbamazapine Lamotrigine Gabapentin Antimanic Antidepressant Prevention Side effects

62. Antipsychotics Atypical (olanzapine) Classic May be as effective Early and late effect

63. Sedatives Acute use

64. Other Diagnoses

65. Other Episodes Mixed Hypomanic

66. Other Mood Disorders Dysthymic Disorder Cyclothymic Disorder Bipolar II Due to a generalized medical condition Substance Induced NOS