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
• 2nd 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
 Course and Prognosis of Mood
Disorders

• Recovery
• Relapse
• Recurrence
90
80
70
60
50
40
30
20
10
0
0.5 1 2 4 5
Recovery
 Predictors
• # Episodes
• Length of episodes
• Symptoms
– # and type
• Comorbidity
 Risk of Suicide

• Depression
– 10-15% severe (hosp) pts
 Treatment

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

• Depression
– Pharmacological
– Psychotherapy
– Other somatic treatments
Antidepressants
 Antidepressants
• 1st generation
– Monoamine Oxidase Inhibitors (MAOIs)
– Tricyclic Antidepressants (TCAs)
• 2nd
– Serotonin reuptake Inhibitors (SSRIs)
– Other specifics (Buproprion, Trazodone)
• 3rd
– 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 3rd 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? Lithium

– Augment? Thyroid hormone

– New drug? Stimulants

Atypical Antipsychotics
2nd 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