Transcript MOOD DISORDERS

MOOD DISORDERS
Dr Nesif J. Al-Hemiary
MBChB - FICMS(Psych)
International Associate
RCPsych.(UK)
Definition
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Mood :is the sustained internal emotional state of the person, while
the affect is the external expression of the present emotional
content.
Mood may be normal (euthymia) ,elevated or depressed.
Ordinarily people experience a wide range of moods and have
equally large repertoire of affective expressions; they feel in control
more or less, of their moods and affects.
In mood disorders , the sense of control is lost ,and people
experience great distress.
Patients with an elevated mood (mania) show expansiveness, flight
of ideas, decreased sleep, heightened self-esteem and grandiose
ideas.
Patients with depressed mood (depression) have a loss of energy
and interest ,feeling of guilt, difficulty in concentrating, loss of
appetite, and thoughts of death and suicide.
The lifetime prevalence of mood disorders has been variously
reported as 2-25%.
Classification
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A- Depressive disorders (unipolar disorders):
1. Major depressive disorder.
2. Dysthymic disorder.
B- Bipolar disorders :
1. Bipolar I disorder.
2. Bipolar II disorder.
3. Cyclothymic disorder.
C- Mood disorders due to general medical
condition.
D- Mood disorder due to substance abuse.
Major Depressive Disorder
(MDD)
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Common disorder, with a lifetime prevalence of
about 15% ,perhaps as high as 25% in women.
The incidence of major depressive disorder is
also high in primary care patients ,in whom it
approaches 10%, and in medical inpatients , in
whom it approaches 15%.
An almost universal observation , is the two-fold
greater prevalence of the disorder in women
than in men.
The reasons for this difference have been
hypothesized to involve hormonal differences,
the effect of childbirth, and differing
psychosocial stresses for women and for men.
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The mean age of onset is about 40 years ; 50%
of all patients have an onset between age of 2050 .
Although uncommonly, MDD can also begin in
childhood or in old age.
Some recent studies suggest that the incidence
of MDD may be increasing among people less
than 20 years old.
MDD occurs most often in people without close
interpersonal relationships or in those who are
divorced or separated .
No correlation have been found between socioeconomic status and MDD.
Etiology
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Although the etiology of MDD is ambigous and complex, it can be
divided into three main groups: biological ,genetic ,and
psychosocial.
Biological factors:
a. Biogenic amines :norepinephrine , and serotonin are the most
implicated.
b. Other neuro-chemical factors: GABA ,and neuroactive peptides
particularly vasopressin, and the endogenous opiates.
c. Neuro-endocrine regulation :adrenal , thyroid and growth
hormone.
d. brain imaging abnormalities: still inconclusive.
Genetic factors :
genetic data strongly indicate that significant genetic factor is
involved in the development of mood disorders. First degree
relatives of MDD are 1.5-2.5 times more likely to have bipolar I
disorder, and 2-3 times to have MDD. The concordance rate for
MZ twins is about 50% while in DZ twins is 10-25%.
3. Psychosocial factors :
a- life events and environmental stress:
The life event most often associated
with a person later development of
depression is losing a parent before the
age of 11. The environmental stressor
most often associated with the onset of an
episode is the loss of a spouse.
b- Family.
c- premorbid personality factors.
d- learned helplessness.
e- cognitive theory.
Clinical Features
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The key symptoms of depression are : a depressed
mood, and a loss of pleasure and interest.
Patients may say that they feel blue ,hopeless, in the dumps,
or worthless. The depressed mood often has a distinct quality
that differentiates it from the normal emotion of sadness or
grief. Patients often describe depression as one of agonizing
emotional pain & sometimes complain about being unable to
cry.
About 2/3 of all depressed patients contemplate (think) about
suicide and 15% commit suicide.
Almost all depressed patients complain about reduced energy
,they find difficulty in finishing tasks ,are impaired at school
and work and have decreased motivation to undertake new
projects.
Most patients complain of trouble in sleeping ,especially early
morning awakening (terminal insomnia) & multiple
awakenings at night.
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Many patients have decreased appetite and weight loss
but others experience increased appetite and weight
gain and sleep longer than usual (atypical features).
Anxiety is a common feature of depression(90%)
The various changes in food intake and rest can
aggravate co-existing medical illness such as DM,
Hypertension, chronic obstructive lung disease and heart
disease.
Other vegetative symptoms include abnormal menses ,
and decreased interest and performance in sexual
activity.
About 50% of patients describe a diurnal variation in
their symptoms with an increased severity in the
morning and a lessening of symptoms by evening.
Cognitive symptoms include poor concentration and
impairment in thinking.
Somatic complaints, substance abuse (especially alcohol)
often complicate the disorder.
Diagnostic Criteria
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DSM-IV-TR Criteria for Major Depressive Episode
Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.
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depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad or empty) or observation made by others (e.g.,
appears tearful). Note: In children and adolescents, can be irritable mood
markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated by either subjective account or
observation made by others)
significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly
every day. Note: In children, consider failure to make expected weight gains.
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down)
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others)
recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing
suicide
Diagnostic criteria
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The symptoms do not meet criteria for a mixed episode.
The symptoms cause clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g.,
hypothyroidism).
The symptoms are not better accounted for by
bereavement, i.e., after the loss of a loved one, the
symptoms persist for longer than 2 months or are
characterized by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation.
(From American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. 4th ed. Text rev.
Washington, DC:
Differential Diagnosis
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Medical disorders.
Neurological disorders.
Mental disorders.
Uncomplicated bereavement.
Prognosis
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Major depressive disorder is not a benign disorder.
It tends to be chronic and patients tend to relapse.
Recurrences are also common.
The incidence of relapse is lower in patients who
continue prophylactic psychopharmacological treatment.
Generally as patient experiences more and more
depressive episodes , the time between episodes
decreases and the severity of each episode increases.
Treatment
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Aims of treatment: include
The patient’s safety should be guaranteed.
Complete diagnostic evaluation.
Treatment plan that addresses not only the
immediate symptoms but also the patient’s
prospective wellbeing.
Treatment must reduce the number and
severity of stressors in the patient’s life.
Hospitalization
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The first and most critical decision is whether to
hospitalize the patient or to attempt outpatient
treatment.
Indications for hospitalization include:
Need for diagnostic procedures.
Risk of suicide or homicide.
Patient’s grossly reduced ability to get food and
shelter.
History of rapidly progressing symptoms.
Rupture of the patient’s usual support systems.
Psychosocial Therapies
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These include three types:
Cognitive therapy: originated by Aron Beck,
focuses on the cognitive distortions postulated
to be present in MDD.
Interpersonal therapy: developed by Gerald
Klerman ,focuses on one or two of the
patient’s current interpersonal problems.
Behavioral therapy: based on the hypothesis
that maladaptive behavioral patterns result in
a person’s receiving little positive feedback
,and perhaps outright rejection, from society.
Other types of treatments include
psychoanalytically oriented therapy, and family
therapy.
Pharmacotherapy
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Effective and specific treatments such as tricyclic drugs
for MDD are available since more than 45 years.
Antidepressant drugs ,although effective, have many
problems; effects need more than 2 weeks to begin, and
their side effects although newer antidepressants have
less side effects.
Tricyclic antidepressants:
they are effective but have many side effects especially
in higher doses and are dangerous in overdose. Side
effects include sedation, postural hypotension, blurred
vision, dry mouth, constipation, retention of urine in
patients with prostatic hypertrophy, cardiac effects, etc..
Examples: amitriptyline, imipramine, clomipramine,
maprotiline, trimepramie, desipramine, etc…
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Serotonin-specific reuptake inhibitors (SSRIs):
they are safer than tricyclic AD but may cause sleep
disturbance (insomnia), GI symptoms, irritability and
sexual dysfunction. They are less effective in severe
cases. Examples : fluoxetine, paroxetine, citalopram,
escitalopram, sertraline and fluvoxamine.
Monoamine oxidase inhibitors (MAOIs):
examples: phenelzine ,isocarboxazide and
tranylcypromine; their use need dietary restriction (the
avoidance of foods with high content of tyramine) to
avoid development of a severe elevation in blood
pressure called hypertensive crisis. There are also many
other side effects like insomnia, postural hypotension
and sexual dysfunction. They are especially useful in
depression with atypical features.
The newer types are reversible inhibitors of the
monoamine oxidase and they are much safer ,not need
dietary restriction and have very low profile of adverse
effects. Example is moclobemide.
Other treatments
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Electro-convulsive therapy (ECT):
It is effective treatment and indicated in the
following states:
Severe cases when rapid improvement is
needed (high risk of suicide).
Drugs are not effective.
Drugs cannot be tolerated.
Phototherapy :
is useful in patients with seasonal depression
and in patients with cyclic recurrences.
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