MOOD DISORDERS

• The term “Mood disorders” groups together a

number of clinical conditions whose common
and essential feature is a disturbance of
mood, accompanied by related cognitive,
psychomotor, psycho- physiological and
interpersonal difficulties
• It is accompanied by a full or partial manic or
depressive episode which are not due to any
other physical or mental disorder
• “Mood” refers to an internal emotional state
of an individual. While “Affect” is the external
expression of internal emotional content
• BIPOLAR AFFECTIVE DISORDER BPAD UNIPOL
AR Recurrent Episodes of Depression BIPOLA
R
BIPOLAR I {Mania & Depression} BIPOLAR II
{Hypomania & Depression} BIPOLAR III
{Depression
Characterized by recurrent episodes of mania
and depression
in the same patient at different times
 MANIA: The central features of mania are elevated
mood, increased activity, and self- important ideas.
 HYPOMANIA: Distinct period of at least a few days of
mild elevation of mood, positive thinking, increased
energy & activity level without manic episode
• DEPRESSION: A change of affect is regarded as the central
clinical feature, mood is depressed, loss of interest, guilt &
suicides etc.
• DYSTHYMIC DISORDER: Denote subsume depressive neurosis,
neurasthenia and other mild chronic depression.
• CYCLOTHYMIC DISORDER: Mood swing between short period
of mild depression & hypomania never reach the severity or
duration of major depression or full mania episode
• Hypomania
• the ability to
function
becomes much
better & marked
increase in
productivity and
creativity
 Mania
• Marked increase in activity
with excessive planning
• Marked increase in sociability
even with previously unknown
people
• Poor judgement. Often involve
in high risk activities such as
reckless driving, distributing
money to strangers
• Usually dressed up in gaudy
and flamboyant clothes
 Other features:
• Decreased need of sleep
• Increased appetite 
later decreased food
intake d/t overactivity
• Absent insight into
illness
• Psychotic features 
delusions, hallucinations
(mood incongruent
psychotic features)
• ICD – 10 CLASSIFICATION
• F 30 – 39 Mood Affective Disorder
• F30 Manic episode
• F31 Bipolar Affective Disorder
• F32 Depressive Episode
• F33 Recurrent Depressive Disorder
• F34 Persistent Mood Disorders
• F38 Other Mood Disorders
• F39 Unspecified Mood Disorder
MANIC EPISODE
• Life-time risk: 0.8-1.0%
• Tends to occur in episodes
lasting usually 3-4 months
 followed by complete
clinical recovery  future
episodes
(manic/depressive/mixed)
 Characterised by the
following features :

 Elevated, expansive or
irritable mood
 Psychomotor activity
 Speech and thought
 Goal-directed activity
 Other features
 Absence of underlying
organic cause (which should last for at least 1
week and cause
disruption in occupational & social
activities)
 The elevated mood
can pass through 4 Ecstasy
stages: Exaltation mood)
(very severe elevation of

(sev elevation of Intense sense of rapture or

Elation mood) blistfullness
(mood elevation of Intense elation with
Euphoria mood)
A feeling of
delusion of
grandeur
Stupurous mania
(stage III)
(mild elevation of confidence and
mood) enjoyment,
an increased sense of increase in Severe mania
psychological well- psychomotor (stage III)
being and happiness activity
Mania (stage II)
Hypomania
(stage I)
 Speech and
thought Since these psychotic
• More talkative than usual symptoms are in
keeping with the
• Describes thoughts racing in mind elevated mood state,
• Develops pressure of speech these are called
mood-congruent
• Uses playful language psychotic features

• (joking/teasing)
• Speaks loudly
• Flight of ideas
• Delusion of grandeur
• Delusion of persecution
• Hallucinations, often with religious content
Goal-directed
activity
Unusually alert,
trying to do many
things at one time
DEPRESSIVE EPISODE
• Life time risk of common
depression:
• 8-12% (in males)
• 20-26% (in females)

• Life time risk of major

depression/
depressive episode is
about 8%
 Characterised by the
following features :

 Depressed mood
 Depressive ideation / cognition
 Psychomotor activity
 Physical symptoms
 Biological functions
 Psychotic features
 Suicide
 Absence of underlying organic
cause
(which should last for at least 2 weeks for a
diagnosis to be made)
 Depressed
mood
• Sadness of mood and loss of
interest/pleasure in almost all activities
(pervasive sadness)
• Present throughout the day (persistent
sadness)
• Varies from day to day and often
unresponsive to the environmental
stimuli
• Results in social w/drawal, decreased
ability to
function in occupational and
interpersonal areas
and decreased involvement in
previously pleasurable activities
• Severe depression  complete
anhedonia
(inability to experience
pleasure)
 Depressive ideation/cognition

Sadness of mood usually

associated with pessimism, which
can result in
3 common types of depressive
ideas:

• Hopelessness (no hope in future)

• Helplessness (no help is possible
now)
• Worthlessness
(feeling of
inadequacy/inferior
ity)
 Depressive
ideation/cognition
• Other features:
• Difficulty in thinking/concentrating
• Indecisiveness
• Slowed thinking
• Poor memory
• Lack of initiative and energy
• Thoughts of death
• Suicidal ideas
• Delusion of nihilism

“My world is coming to an

end” “My intestines have
rotted away”
 Psychomotor
activity
• Young patient (<40 years)  retardation is
common
• Slowed thinking and activity, decreased energy,
monotonous
voice.
• Severe  stuporous (depressive stupor)

• Older patients  agitation is common

• Marked anxiety, restlessness (inability to sit still,
hand-wriggling)
• Subjective feeling of unease

• Anxiety is a frequent accompaniment of

depression
• Irritability (easy annoyance and frustration in day to
day activities)
 Physical
symptoms

• Multiple physical
symptoms (general aches
and pain)
• Complain of reduced
energy and easy fatigability
• Consult a physician
instead of
psychiatrist
 Psychotic
features
• 15-20% of depressed patients have
psychotic features such as
delusions, hallucinations, grossly
inappropriate behavior or stupor
• Mood-congruent psychotic
features  nihilistic delusions,
delusion of guilt, delusions of
poverty, stupor
• Mood-incongruent psychotic
features 
delusions of control
Suicide
• Should always be taken seriously
• Factors increase the risk of suicide
• Presence of marked hopelessness
• Males; age>40; unmarried;
divorced/widowed
• Written/verbal communication of
suicidal
intention/plan
• Early stages of depression
• Recovering of depression
• Period of 3 months from recovery
RECURRENT
DEPRESSIVE
DISORDER
• Characterized by recurrent (at least 2) depressive
episodes (unipolar depression)
• The current episode in recurrent depressive
disorder is specified as one of the following:
• Mild
• Moderate
• Severe, without psychotic symptoms
• Severe, with psychotic symptoms
• In remission
PERSISTENT MOOD DISORDER
Characterized by persistent mood
symptoms which last for >2 years
(1 year in children)
But not severe enough to be labelled as
even hypomanic or mild depressive
episode

• Persistent mild depression 

dysthymia
• Persistent instability of mood
between mild depression and mild
elation  cyclothymia
OTHER MOOD DISORDER
• Includes the
diagnosis of
mixed affective
episode
• Frequently missed
diagnosis clinically
• Full clinical picture of
depression and mania
is present either at
the same time
intermixed or
alternates rapidly with
each other (rapid
cycling), without a
normal intervening
period of euthymia
 ETIOLOGY
• 1) BIOLOGICAL THEORIES
•  Catecholamine Hypothesis: The activity of
catecholamine is too high or low.
•  Serotonin Hypothesis: Deficiency in
serotonin activity in both mania & depression
may be seen.
•  GABA Hypothesis of Mania: Deficiency has
been postulated to contribute to the etiology of
psychotic states, especially Mania
 ETIOLOGY
• NEURO ENDOCRINAL ASPECTS:
•  Hypothalamic- Pituitary- Adrenal Axis (HPA
Axis): Neurons in the Peri-ventricular nucleus
release corticotrophin releasing hormone
(CRH), which stimulates the release of (ACTH)
from the pituitary.
•  Melatonin: It is decreased in depression and
increased in mania.
 ETIOLOGY
• GENETIC STUDIES Identical twins
(monozygotic) have a 54% risk of one twin
developing depression if the other has had a
diagnosed episode, risk of developing
depression in non identical (dizygotic) twins is
about 24% higher than that of general
population but less than that for monozygotic
twins.
 ETIOLOGY
• PSYCHOSOCIAL THEORIES 1) Life events and
environmental stress: Stressful life events more
often precede the first episodes of mood disorders
than the subsequent episodes.

• 2) Premorbid personality factors: There are certain

personality characteristics, such as lack of energy,
breakdown under stress, introversion, insecurity,
tendency to worry, dependency & obsessionality
 PSYCHOPATHOLOGY
• Adolph Meyer believed depression to be the
person’s reaction to a disturbing life experiencing
such as the loss of a loved one, financial set back
or unemployment
• According to Beck, depression results from faulty
cognition. He discussed a cognitive triad,
consisting of: 1) Perceiving oneself as defective &
inadequate. 2) Perceiving world as demanding &
punishing. 3) Expecting failure, defeat and
hardship
 CLINICAL MANIFESTATION
• Major depression: 1) Depressed Mood 2) Loss
of Interest 3) Anxiety 4) Insomnia 5) Suicide 6)
Guilt 7) Somatic symptoms 8) Retardation 9)
Agitation 10) Diurnal variation of symptoms
• Mania: 1) Mood 2) Thought 3) Speech 4)
Activity 5) Sleep 6) Appetite 7) Libido 8)
Appearance 9) Insight
 CLINICAL MANIFESTATION
• Dysthymic Disorders: 1) Milder form of
depressive symptoms 2) Diurnal variation 3)
Feeling of sadness 4) Lack of interest in daily
activity 5) Nihilism, Demanding, Complaining
6) Change in appetite 7) Decreased sexual driv
 DIAGONISTIC CRITERIA
• Manic Episode
• 1) A distinct period of abnormally & persistently elevated,
expansive or irritable mood lasting at least 1 week.
• 2) During the period of mood disturbance, three (or more) of the
following symptoms have persisted:
•  Inflated self-esteem or grandiosity
•  Decreased need for sleep
•  More talkative than usual or pressured to keep talking
 Flight of ideas
•  Distractibility
•  Increase in goal- directed activity or psychomotor agitation
•  Excessive involvement in pleasurable activities that have a high
potential for painful consequences
 DIAGNOSTIC CRITERIA (DSM-IV)
.  Major Depressive Episode
1) Five (or more) of the following symptoms have been present during the
same 2- week period and represent a change from previous
functioning;
 Depressed mood
 Markedly diminished interest or pleasure
 Significant weight loss
 Insomnia or Hypersomnia
 Fatigue or loss of energy
 Feeling of worthlessness
 Recurrent thoughts of death
 DIAGNOSTIC CRITERIA (DSM-IV)
•  Dysthymic Disorder
• 1) Depressed mood for most of the day
• 2) 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
 ASSESSMENT
• History taking,
• Physical Examination
• Mental Status Examination .
• The special assessment of patient with mood
disorders are as follows:
• 1) Dexamethasone Suppression Test (DST)
• 2) Rating Scales:  Beck Depression Inventory
(BDI)  Zung Rating Scale  Hamilton Depression
Rating Scale (HDRS)
TREATMENT MODALITIES OF PATIENT WITH
MOOD DISORDERS: 1) Pharmacologic
Treatments  Tricyclic Antidepressants  Mono
amine oxidase inhibitors  Selective Serotonin
reuptake inhibitors 2) Electroconvulsive Therapy
3) Psychotherapeutic Approach  Supportive
Psychotherapy  Brief therapy  Interpersonal
therapy  Cognitive Behavior therapy  Marital
Therapy and Family Therap
 Lithium
• Drug of choice for tx of manic
episode (acute phase) as well as
for prevention of further episodes
in BPD
• 900-1500mg of lithium
carbonate/day
• Need to be closely monitored by
repeated blood levels, as the
difference between the therapeutic
and lethal blood levels is not very
wide (narrow therapeutic index)
• Therapeutic blood lithium = 0.8-
1.2mEq/L
• Prophylactic blood lithium = 0.6-
1.2mEq/L
• Blood lithium level of >2.0mEq/L is often asst.
with toxicity
• A level >2.5-3.0 mEq/L may be lethal
• The common acute toxic symptoms are
neurological
• The common chronic side effects are
nephrological and endocrinal (usually
hypothuroidism)
• Most important investigations before starting
lithium include complete GPE, CBC, ECG,
urine R/E, RFT, TFT
 Antipsychotics

• Important adjunct in the tx of mood disorder

• Commonly used drugs:
• Risperidone
• Olanzapine
agranulocytosis
• Clonazepine
• Quetiapine*
• Haloperidol
• Aripiprazole*
*safe from metabolic
syndrome
Other Mood Stabilizers
• Sodium valproate (1000-3000mg/day)
• Carbamazepine (600-1600mg/day)
• Benzodiazepines
(Lorazepam/clonazepam) as adjuvants
• Lamotrigine
• T3 and T4 as adjuncts
 Psychosocial
treatment
• Cognitive behavior
therapy
• Interpersonal therapy
• Psychoanalytic
psychotherapy
• Behaviour therapy
• Group therapy
• Family & marital
therapy