Depressive Illness,

Unipolar and Bipolar

Affective Disorder
 Objectives
• To acquire knowledge about various Mood/ Affective Disorders
• To know conceptualization of Bipolar Disorders and Major Depressive
Disorder
• To identify clinical features (signs/symptoms) of mood disorders
• To know management of mood disorders
 Introduction
• Mood is a pervasive and sustained feeling tone that is experienced
internally and that influences a person's behavior and perception of the
world
• Affect is the external expression of mood
• Mood can be normal, elevated, or depressed
• Healthy persons experience a wide range of moods and have an equally
large repertoire of affective expressions; they feel in control of their
moods and affects
• Mood disorders are a group of clinical conditions characterized by a loss
of that sense of control and a subjective experience of great distress
• These disorders are associated with impaired interpersonal, social, and
occupational functioning
 Contd.

• Patients afflicted with only major depressive episodes are said to have major
depressive disorder or unipolar depression
• Patients with both manic and depressive episodes or patients with manic episodes
alone are said to have bipolar disorder
• The terms unipolar mania and pure mania are sometimes used for patients who
are bipolar, but who do not have depressive episodes
• Hypomania is an episode of manic symptoms that does not meet the full (DSM-IV-
TR) criteria for manic episode.
• Cyclothymia and dysthymia are defined by DSM-IV-TR as disorders that represent
less severe forms of bipolar disorder and major depression, respectively.
 History
• Hippocrates used the terms mania and melancholia to describe mental disturbances
• Emil Kraepelin, described manic-depressive psychosis using most of the criteria that
psychiatrists now use to establish a diagnosis of bipolar I disorder
 Epidemiology
• Mood disorders are common
• Major depressive disorder has the highest lifetime prevalence (almost 17 percent) of
any psychiatric disorder
• lifetime prevalence for bipolar disorder is 0 to 2.4%
• Major depressive disorder is two times more common in females
• bipolar I disorder has an equal prevalence among men and women
• Women have a higher rate of being rapid cyclers, defined as having four or more
manic episodes in a 1-year period
• Mean age of onset for bipolar disorder 30 years
• Mean age of onset for major depressive disorder 40 years
 Etiology
 Biological Factors:
• Neurotransmitter: (Monoamine hypothesis)norepinephrine and serotonin are most
implicated in the pathophysiology of mood disorders
• Neuroanatomy: the prefrontal cortex (PFC), the anterior cingulate, the hippocampus,
and the amygdala
• Genetic factors: if one parent has a mood disorder, a child will have a risk of
between 10 and 25 percent for mood disorder. If both parents are affected, this risk
roughly doubles
 Etiology
 Psychosocial factors:
• Life Events and Environmental Stress
• Personality Factors: Persons with certain personality disorders histrionic, and
borderline may be at greater risk for depression
• Psychodynamic Factors in Depression: disturbances in the infant mother
relationship during the oral phase
• Psychodynamic Factors in Mania: Klein viewed mania as a defensive reaction to
depression, using manic defenses such as omnipotence, in which the person develops
delusions of grandeur
 Depressive Disorders in DSM-V
• Major depressive disorder
--Prominent depressive symptoms meeting criteria for major depressive episode
• Dysthymic disorder
--Prominent depressed mood lasting for 2 years
• Substance induced mood disorder with depressive features
--Prominent depressive symptoms during/within 1 month of substance use
• Mood disorder due to a general medical condition with depressive
features
--Symptoms as direct physiologic consequence of GMC
• Adjustment disorder with depressed mood
--Symptoms arise in response to identifiable stressor(s)
• Depressive disorder NOS
Prominent depressive symptoms not meeting other criteria
 Contd.
 Major Depressive episode:
• A major depressive episode must last at least 2 weeks.
• At least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure
• There should be least four symptoms from the following: changes in appetite
and weight, changes in sleep and activity, psychomotor
agitation/retardation,lack of energy, feelings of worthlessness/guilt, problems
thinking/concentrating and making decisions, and recurring thoughts of death
or suicide.
Mild
Moderate
Severe without psychotic features
Severe with psychotic features: mood congruent/ mood incongruent
In Full remission
 Contd.

 Major Depressive Disorder:

• Presence of one or more major depressive episode(s).
• The major depressive episode(s) not better accounted for by schizoaffective
disorder/ schizophrenia/ delusional disorder or other psychotic disorders.
• There has never been a manic episode/ hypomanic episode or mixed episode
Chronic Major depressive Disorder: for past 2 years
MDD with catatonic features specifier: atleast two of the following are present:
motoric immobility/ stupor. Excessive motor activity. Extreme negativism.
Peculiar movements. Echolalia/ echopraxia
MDD with postpartum onset specifier: Onset within 4 weeks of postpartum
MDD with seasonal pattern specifier
 Melancholic Depression
• Melancholia is one of the oldest terms used in psychiatry
• It is used to refer to a depression characterized by:
-severe anhedonia
-early morning awakening
-weight loss
-profound feelings of guilt (often over trivial events)
It is not uncommon for patients who are melancholic to have suicidal ideation
Also called as endogenous depression
 Atypical depression
• Mood reactivity (i.e., mood brightens in response to actual or potential positive
events)
• Two (or more) of the following features:
– significant weight gain or increase in appetite
– hypersomnia
– leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
– long-standing pattern of interpersonal rejection sensitivity (not limited to episodes
of mood disturbance) that results in significant social or occupational impairment
 Reversed vegetative symptoms
 Younger age of onset
 Contd.

 Dysthymic disorder:
A. Depressed mood for most of the day, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
• poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness

C. The person has never been asymptomatic during this period

D. No major depressive episode has been present during the first 2 years of the disturbance
E. There has never been a manic/hypomanic or mixed episode
 Bipolar Disorders in DSM-IV-TR

• Bipolar I disorder
• Bipolar II disorder
• Cyclothymia
• Substance induced mood disorder with manic/ mixed features
• Mood disorder due to a general medical condition with manic/ mixed
features
• Bipolar disorder NOS
 Contd.
• A manic episode is a distinct period of an abnormally and persistently
elevated, expansive, or irritable mood lasting for at least 1 week, or
less if a patient must be hospitalized.
• During the period of mood disturbance, three (or more) of the
following symptoms have persisted (four if the mood is only irritable)
and have been present to a significant degree:
– inflated self-esteem or grandiosity
– decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
– more talkative than usual or pressure to keep talking
– flight of ideas or subjective experience that thoughts are racing
– distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
– increase in goal-directed activity
– excessive involvement in pleasurable activities that may have painful consequences
(sexual indiscretions, or foolish business investments)
 Contd.

• Psychotic symptoms in mania: in its most severe form, mania may be associated with
psychotic symptoms
• A hypomanic episode lasts at least 4 days and is similar to a manic episode except
that it is not sufficiently severe to cause impairment in social or occupational
functioning, and no psychotic features are present.
• Both mania and hypomania are associated with inflated self-esteem, decreased
need for sleep, distractibility, great physical and mental activity, and
overinvolvement in pleasurable behavior
• A mixed episode is a period of at least 1 week in which both a manic episode and a
major depressive episode occur almost daily.
 Contd.

• bipolar I disorder is defined as having a clinical course of one

or more manic episodes and, sometimes, major depressive
episodes.
• A variant of bipolar disorder characterized by episodes of
major depression and hypomania rather than mania is known
as bipolar II disorder.
• Cyclothymic disorder is characterized by at least 2 years of
frequently occurring hypomanic symptoms that cannot fit the
diagnosis of manic episode and of depressive symptoms that
cannot fit the diagnosis of major depressive episode.
 Rapid cycling bipolar I/II disorder
• More common in females
• external factor such as stress or drug treatment may be involved in the pathogenesis
• At least four episodes of a mood disturbance in the previous 12 months that meet
criteria for a major depressive, manic, mixed, or hypomanic episode
• Episodes are demarcated either by partial or full remission for at least 2 months
 Differential Diagnosis
 Mood disorders due to general medical conditions
• Endocrine disorders
• Mania: Hyperthyroidism; Depression: Hypothyroidism, Cushing syndrome
 Substance induced Mood disorders
 Other Psychiatric Disorders
• Schizophrenia
• Schizoaffective disorders
• Acute/ transient psychotic disorders
• Adjustment disorders with depressed mood
• Generalized anxiety disorders/ Obsessive compulsive disorder
 Course and Prognosis
• Major depressive disorder is not a benign disorder
• It tends to be chronic, and patients tend to relapse
• Mild episodes, the absence of psychotic symptoms, short hospital stay, stable family
functioning, and generally sound social functioning are good prognostic indicators
• Patients with bipolar I disorder have a poorer prognosis than do patients with major
depressive disorder
• Bipolar I disorder with an early onset, premorbid poor occupational status, alcohol
dependence, psychotic features, interepisode depressive features, and male gender is
associated with a poor prognosis
 Management
• Hospitalization:
 Indications: risk of harm to self/others/ property, severe depressive/psychotic
symptoms, history of rapidly progressing symptoms, patient's grossly reduced ability
to get food and shelter, and the need for diagnostic procedures, rupture of a patient's
usual support systems, initiation of ECT, treatment resistant depression
 Manic patients often have a complete lack of insight into their disorder that
hospitalization seems absolutely absurd to them
 Pharmacological Treatment

 Treatment of Major Depressive Disorder:

• Antidepressants:
 Tricyclic antidepressants
 Selective serotonine reuptake inhibitors
 Serotonine norepinephrine reuptake inhibitors(venlafaxine)
 Dopamine reuptake inhibitor(bupropion,naltrexone,wellbutrin)

Antidepressant treatment should be maintained for at least 6 months or the length of a

previous episode, whichever is greater.
 Contd.

 Treatment of Bipolar Mood Disorder:

• Treatment of Acute Manic Episode:
 Mood stabilizers: Sodium Valproate, Lithium Carbonate,
Carbamazepine, Oxcarbazepine etc.
 Atypical Antipsychotics
 Benzodiazepines (Clonazepam and Lorazepam)
• Treatment of Acute Depressive Episode:
• Antidepressants are recommended to be used only in combination
with mood stabilizers
• Lamotrigine
• Atypical antipsychotics
 Contd.

• Maintenance Treatment of Bipolar

Disorder
• Aim: Prevention of recurrent episodes (mania or depression)
• Mood stabilizers (Sodium Valproate, Lithium, carbamazepine)
alone or in combination, are the most widely used agents in
the long-term treatment of patients who are bipolar.
• Lamotrigine has prophylactic antidepressant and, potentially,
mood-stabilizing properties.
• Atypical antipsychotics
• Suicide prevention: Lithium
 Treatment Resistant Depression
• Failure to respond to adequate trials of two to four different antidepressants (plus or minus
ECT)
• Seek answers to these questions:
Is the diagnosis correct?
Are the doses & duration appropriate?
Is patient compliant to medications?
Are there any maintaining factors?
• Treatment options:
Continue monotherapy at maximum tolerable doses
Add psychotherapy
Change antidepressant
Consider augmentation: lithium/atypical antipsychotic/thyroid hormone/lamotrigine
Combine antidepressant from different classes
Electro-convulsive therapy
 Non pharmacologic treatment
• Although most studies indicate and most clinicians and researchers believe that a
combination of psychotherapy and pharmacotherapy is the most effective treatment
for major depressive disorder
• Interpersonal therapy (Gerald Klerman)
• Cognitive therapy (Aaron Beck)
• Family therapy
 Non pharmacologic treatment: Bipolar Disorder

• Interpersonal & social rhythm therapy:

To reduce mood lability maintain regular pattern of daily activities
Evidence suggest improved long term outcome
• Cognitive behavior therapy:
Educate about bipolar disorder & treatment
Teach skills: cope with stressors
Facilitate compliance with treatment
• Family therapy
Psycho-education of patient & family members: accepting reality of illness, identifying precipitating stresses
• Support Groups
Patient may benefit from hearing the experiences of others, struggling with similar issues
 Changes in DSM-V
• Among Bipolar Disorder the diagnosis of Mixed episode is replaced by a new
specifier “with mixed features”.
• A new diagnosis of “Disruptive Mood Dysregulation Disorder” has been
added in DSM-V to avoid overdiagnosis and overtreatment of bipolar disorder
in children. These children present with persistent irritability.
• Major depressive episode presenting with additional manic symptoms (which
don’t fulfill the criteria of manic episode) is represented with a specifier “with
mixed features”
 Take Home Message
• Types of Mood disorders
• Approach to a patient with mood disorders
 History/ MSE; signs/symptoms (Diagnosis)
• Differential diagnoses
• Management of Mood disorders
 Investigations
 Hospitalization
 Pharmacologic treatment
 Non pharmacologic treatment