Mood Disorders Major Depressive Disorder

Definitions: A. 5 symptoms during same 2-week period

Major Depressive Disorder 1. Depressed mood*
Depressive episode lasting at least 2 weeks 2. Diminished interest, pleasure*
Typically at least 4 depressive symptoms 3. Significant weight loss/gain
Mania 4. Insomnia/hypersomnia
Manic: Abnormally and persistently elevated, expansive, 5. Psychomotor agitation (restless, slowed down)
irritable mood lasting 1 week 6. Fatigue/loss of energy
Hypomania: similar to manic episode, but not severe 7. Feeling worthless or excessive inappropriate guilt
enough to impede social/work functioning; lack of psychotic 8. Diminished ability to think/concentrate/indecisive
features 9. Recurrent thoughts of death/suicide
Dysthymia depressed mood for 2 years *At least 1 of these symptoms must be depressed mood or loss of
Cyclothymia Frequent hypomanic and depressive symptoms for 2 interest or pleasure
years B. Symptoms cause clinically significant distress/impairment in social/work
MDD Bipolar I functioning
C. Not attributable to substances/meds or organic medical condition
Lifetime Prevalence 17%** 0-2.4% *A + B + C = Major Depressive Disorder
D. The patients symptoms are not better explained by other psychological
Gender W>M 2:1 W=M illness
Age of Onset Average 40 yo 5-50 yo E. There has never been manic/hypomanic episode

Marital Status Lack close Divorced or Single *Need to specify Single or Recurrent
relationships Recurrent: 2 consecutive months between 2 separate episodes in
which criteria are not met for a major depressive episode (no
Socioeconomic Status No Correlation Upper Class,
No College Degree
symptoms)
Specifiers
o Anxious distress
Etiology: o Mixed features
Neurotransmitter disturbances: NE, serotonin, dopamine o Melancholic features
Alterations of hormonal regulation: o Atypical features
Elevated HPA activity & cortisol o Psychotic features
Thyroid dysfunction o Mood-congruent psychotic features
GH o Catatonia
Alterations of sleep neurophysiology o Peripartum onset
Immunologic disturbances o Seasonal pattern
Structural and functional brain abnormalities o In partial/full remission
Genetic factors o Mild/moderate/severe
Psychosocial factors stress, personality
Course
Comorbid Conditions: Untreated episode lasts 6-13 months
Anxiety 5-10% develop manic episodes 6-10 years after first depressive
Alcohol/substance abuse or dependence episode
Panic disorder Some clinicians then switch dx to Bipolar
OCD Prognosis:
Social anxiety disorder Chronic with relapses
Eating disorders 50% of those hospitalized for 1st episode recovery within 1st year
25% recurrent episode within 6 months
SIG E. CAPS 30-50% recurrent episode within 2 years
S - sleep 50-75% recurrent episode within 5 years
I - interest
G - guilt Pharmacotherapy - Depression
E - energy Antidepressants
C - concentration Choose based on side-effect profile
A - appetite Raise dose to maximum recommended level x 4-5 weeks before
P - psychomotor determining efficacy
S - suicidal Maintain therapy for at least 6 months or length of previous episode
Consider prophylactic therapy
Maintenance therapy for chronic depression
Bipolar Disorder
Criteria must be met for at least one manic episode.
The manic episode may have been preceded by and may be followed
by hypomanic or MDD
Manic Episode (Bipolar I)
A. Abnormally & persistently elevated, expansive or irritable
mood, increased energy lasting 1week
B. Plus 3 of the following:
1. Inflated self-esteem/grandiosity
2. Decreased need for sleep
3. Talkative/pressure to keep talking
4. Flight of ideas/racing thoughts
5. Distractibility
6. Increased goal-driven activity/psychomotor
agitation
7. Excessive participation in risky activities
C. Mood is severe enough to impair social/work functioning; may
need hospitalization
D. Mood not attributable to substances/meds
Hypomanic Episode (Bipolar II):
As above however:
Episode lasts > 4 consecutive days
Clear change in mood from patients normal
Pt is able to function socially/work, etc; does not
require hospitalization
Major Depressive Disorder (same as previous)
5 symptoms during same 2-week period
Depressed mood*
Diminished interest, pleasure*
Significant weight loss/gain
Insomnia/hypersomnia
Psychomotor agitation (restless, slowed down)
Fatigue/loss of energy
Feeling worthless or excessive inappropriate guilt
Diminished ability to think/concentrate/indecisive
Recurrent thoughts of death/suicide
*At least 1 of these symptoms must be depressed mood or
loss of interest or pleasure
Criteria have been met for at least one manic episode
Symptoms not better explained by other psychologic illness
Tx Considerations for MDD & Bipolar
Safety
Complete diagnostic evaluation
Address immediate symptoms AND long-term
Patients overall well being
Hospitalization
Risk of suicide/homicide
Inability to provide food, shelter or diagnostic procedures
Hx rapidly progressing symptoms
Lack of support system in place
Alternative therapies
Vagal nerve stimulation
Transcranial magnetic stimulation
Sleep deprivation (mania)
Phototherapy
Dysthymia
Persistent depressive disorder
Patients say they have always been depressed
Sub-clinical Depression
Low grade chronicity x 2 years
Insidious onset in childhood or teen years
Persistent or intermittent course
Affects 5-6% of general population
Table 8.2-1 DSM 5 Criteria for Dysthymia
Tx: none or psychotherapy
Cyclothymia
Mild form of Bipolar II
Chronic, fluctuating mood disorder
3-5% of psychiatric patients
Consider dx in patient with seemingly sociopathic behavioral problems,
relationship instability or promiscuity
Behaviors hinder friendship, work, school, etc
1/3 go on to develop Bipolar II
Tx: mood stabilizers, antimanic drugs

Course:
Helpful to graph out course over time
Typically starts as depressive episode
Most experience both depressive & manic episodes
10-20% only manic
Prognosis
Early onset (children/teens) poor prognosis
Bipolar I poorer prognosis than major depressive disorder
40-50% have second manic episode within 2 years
7% have no recurrent symptoms
50-60% achieve significant control of symptoms with Li

Pharmacotherapy Bipolar
Acute Manic Episode: Mood Stabilizers
Lithium: slower onset, sig ADRs, freq lab monitoring
Valproate: faster onset, lab monitoring
Carbamazepine & Oxcarbazepine
Clonazepam & Lorazepam
Atypical & Typical Antipsychotics
Acute depressive phase: Mood Stabilizers + Anti-depressants
Antidepressants alone can induce cycling, mania, or
hypomania
Often used with mood stabilizer in combination
Maintenance phase: Mood stabilizers
lithium, carbamezepine, valproic acid