Transcript Mood disorders

Mood (Affective) Disorders
Department of Psychiatry
1st Faculty of Medicine
Charles University, Prague
Head: Prof. MUDr. Jiří Raboch, DrSc.
Mood (Affective) Disorders
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Mood disorders are very common, their life
prevalence is up to 20 %, and they have a high
level of morbidity and mortality as well as an
immense impact on disabilities worldwide.
The fundamental disturbance is a change in mood
or affect, usually to depression (with or without
associated anxiety) or to elation. The mood change
is usually accompanied by a change in the overall
level of activity.
Most of these disorders tend to be recurrent, and
the onset of individual episodes is often related to
stressful events or situations.
The mood disorders may be subdivided into
unipolar and bipolar types:
1. those that are characterized by depression only
2. those that are characterized by manic episode either
alone or in combination with depression
Classification of Mood Disorders
International Classification of Diseases (ICD10) came into use in WHO Member States as
from 1994
F30
F31
F32
F33
F34
F38
F39
Manic episode
Bipolar affective disorder
Depressive episode
Recurrent depressive disorder
Persistent mood (affective) disorders
Other mood (affective) disorders
Unspecified mood (affective) disorder
Test Methods
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Self-reported scales:
• Young Mania Rating Scale (YMRS)
• Beck scale (depression)
• Zung scale (depression)
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Interview with physician:
• Hamilton scale (HAMD)
• Montgomery and Asberg scale (MADRS)
F32 Depressive Episode
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Pathological sadness
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Depressive episode:
• depressed mood
• loss of interest and enjoyment
• reduced energy leading to increased fatigability
and diminished activity
• marked tiredness after only slight effort
• reduced concentration and attention
• reduced self-esteem and self-confidence
• ideas of guilt and unworthiness
• bleak and pessimistic views of the future
• ideas or acts of self-harm or suicide,
• disturbed sleep and diminished appetite
F32 Depressive Episode
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Clinical presentation shows marked individual
variations
• in some cases, anxiety, distress, and motor agitation
may be more prominent at times than the depression
• the mood change may also be masked (masked
depression) by added features such as irritability,
excessive consumption of alcohol, histrionic behaviour,
and exacerbation of pre-existing phobic or obsessional
symptoms, or by hypochondriacal preoccupations.
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Depressive episode should last at least 2 weeks
(typically several months), but shorter periods
may be reasonable if symptoms are unusually
severe and of rapid onset.
The lifetime prevalence: 17%; risk of recurrence
>50%.
F32 Depressive Episode
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The lowered mood varies little from day to day, is
unresponsive to circumstances and may be
accompanied by so-called „somatic“ symptoms:
• loss of interest or pleasure in activities that are normally
enjoyable (anhedonia)
• lack of emotional reactivity to normally pleasurable
surroundings and events
• waking in the morning 2 hours or more before the usual time
• depression worse in the morning
• objective evidence of definite psychomotor retardation or
agitation
• loss of appetite
• weight loss
• loss of libido
F32 Depressive Episode
F32
F32.0
F32.1
F32.2
Depressive episode
Mild depressive episode
Moderate depressive episode
Severe depressive episode without
psychotic symptoms
F32.3 Severe depressive episode with
psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
F32.0 Mild Depressive Episode
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Two or three of the above symptoms are
usually present.
For mild depressive episode are typical
depressed mood, anhedonia and increased
fatigability. The afflicted person is usually
distressed by the symptoms and has some
difficulty in continuing with ordinary work
and social activities, but will probably not
cease to function completely.
F32.1 Moderate Depressive
Episode
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An individual with moderate depressive
episode suffers from more symptoms
(four or more of the above symptoms are
usually present) of greater severity and
will usually have considerable difficulty in
continuing with social, work or domestic
activities.
F32.2 Severe Depressive Episode
without Psychotic Symptoms
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In a severe depressive episode, the
sufferer usually shows considerable distress
or agitation. Loss of self-esteem or feelings
of uselessness or guilt are likely to be
prominent, and suicide is a distinct danger
in particularly severe cases. ; a number of
"somatic" symptoms are usually present.
• Agitated depression
• Major depression
• Vital depression
F32.3 Severe Depressive Episode
with Psychotic Symptoms
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Psychotic symptoms may be present, such as
• delusions (ideas of sin, poverty or imminent disasters)
• hallucinations (defamatory or accusatory voices or of
rotting filth or decomposing flesh)
• depressive stupor
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Severe ordinary social activities are impossible
When the psychotic symptoms are consistent
with the patient’s mood, they are referred to as
mood congruent, when they are inconsistent,
they are referred as mood incongruent.
Single episodes of:
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major depression with psychotic symptoms
psychogenic depressive psychosis
psychotic depression
reactive depressive psychosis
F33 Recurrent Depressive Disorder
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Recurrent depressive disorder is characterized by
repeated episodes of depression without any history
of independent episodes of mood elevation and
overactivity.
Recovery is usually complete between episodes, but
a substantial part of patients will have a recurrence
and about 30% may develop a persistent
depression.
The lifetime prevalence - about 10—20 %;
women:men 2:1.
The risk of suicide (approximately 10—15%.
Seasonal affective disorder - onset of mood
symptoms is connected with changes of seasons,
with depression typically occurring during the winter
months and remissions or changes from depression
to mania occurring during the spring.
F33 Recurrent Depressive Disorder
remission
severity of depression
no depression
symptoms
recovery
relapse
recurrence
relapse
response
syndrome
treatment stage
6-12
weeks
4-9
months
1 or more
years
time
Kupfer 1991
F33 Recurrent Depressive Disorder
F33
Recurrent depressive disorder
F33.0 Recurrent depressive disorder, current episode
mild
F33.1 Recurrent depressive disorder, current episode
moderate
F33.2 Recurrent depressive disorder, current episode
severe without psychotic symptoms
F33.3 Recurrent depressive disorder, current episode
severe with psychotic symptoms
F33.4 Recurrent depressive disorder, currently in
remission
F33.8 Other recurrent depressive disorders
F33.9 Recurrent depressive disorder, unspecified
F30 Manic Episode
F30
F30.0
F30.1
F30.2
F30.8
F30.9
Manic episode
Hypomania
Mania without psychotic symptoms
Mania with psychotic symptoms
Other manic episodes
Manic episode, unspecified
F30.0 Hypomania
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Hypomania is characterized by
• persistent mild elevation of mood for at least
several days
• increased energy and activity
• usually marked feelings of well-being and both
physical and mental efficiency
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Increased sociability, talkativeness,
overfamiliarity, increased sexual energy,
and a decreased need for sleep are often
present but not to the extent that they
lead to severe disruption of work or result
in social rejection. There are no
hallucinations or delusions
F30.1 Mania without Psychotic
Symptoms
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Mania without psychotic symptoms:
• last for at least 1 weak
• mood is elevated out of keeping with individual’s
circumstances and may vary from carefree joviality to
almost uncontrollable excitement
• elation is accompanied by increased energy, resulting in
overactivity, pressure of speech, and a decreased need for
sleep
• normal social inhibition are lost, attention cannot be
sustained, and there is often marked distractibility
• self-esteem is inflated, and grandiose or over-optimistic
ideas are freely expressed
• perceptual disorders may occur
• the individual may embark on extravagant and impractical
schemes, spend money recklessly, or become aggressive,
amorous, or factious in inappropriate circumstances.
F30.2 Mania with Psychotic
Symptoms
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Mania with psychotic symptoms represents a
more severe form of mania:
• inflated self-esteem and grandiose ideas may develop into
delusions, and irritability and suspiciousness into delusions
of persecution
• in severe cases, grandiose or religious delusions of identity
or role may be prominent, and flight of ideas and pressure of
speech may result in the individual becoming
incomprehensible
• sustained physical activity and excitement may result in
aggression or violence, and neglect of eating, drinking, and
personal hygiene may result in dangerous states of
dehydration and self neglect
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Mania with:
• mood-congruent psychotic symptoms
• mood-incongruent psychotic symptoms
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Manic stupor
F31 Bipolar Affective Disorder
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Bipolar affective disorder is characterized by
repeated, at least two episodes in which the patient’s
mood and activity levels are significantly disturbed
(manic or depressive syndromes, patients who suffer
only from repeated episodes of mania are
comparatively rare).
The first episode may occur at any age from childhood
to old age.
The frequency of episodes and the pattern of
remissions and relapses are both very variable.
The lifetime prevalence is between 0,5 an 1 %.
Suicidality – about 19%. Comorbidity with alcohol and
drug abuse
The rapid-cycling specifier identifies those patients
who have had at least four episodes of a major
depressive, manic, or mixed episode during the past
12 months.
F31 Bipolar Affective Disorder
F31
Bipolar affective disorder
F31.0 Bipolar affective disorder, current episode hypomanic
F31.1 Bipolar affective disorder, current episode manic without
psychotic symptoms
F31.2 Bipolar affective disorder, current episode manic with
psychotic symptoms
F31.3 Bipolar affective disorder, current episode mild or
moderate depression
F31.4 Bipolar affective disorder, current episode severe
depression without psychotic symptoms
F31.5 Bipolar affective disorder, current episode severe
depression with psychotic symptoms
F31.6 Bipolar affective disorder, current episode mixed
F31.7 Bipolar affective disorder, currently in remission
F31.8 Other bipolar affective disorders
F31.9 Bipolar affective disorder, unspecified
F34 Persistent Mood (Affective)
Disorders
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Persistent mood disorders are persistent and
usually fluctuating disorders of mood in which
individual episodes are not sufficiently severe to
warrant being described as hypomanic or even mild
depressive episodes.
Lasting more than 2 years
F34
F34.0
F34.1
F34.8
F34.9
Persistent mood (affective) disorders
Cyclothymia
Dysthymia
Other persistent mood (affective) disorders
Persistent mood (affective) disorder, unspecified
F34.0 Cyclothymia
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For cyclothymia persistent instability of
mood, involving periods of mild depression
and mild elation is typical.
This instability usually develops early in
adult life and pursues a chronic course,
although the mood may be normal and
stable for months at a time.
The mood swings are usually perceived by
the individual as being unrelated to life
events.
F34.1 Dysthymia
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Dysthymia represents a chronic, milder
form of depression which does not fulfill
the criteria for recurrent depressive
disorder especially in terms of severity.
Sufferers usually have periods of days or
weeks when they describe themselves as
well, but most of the time they feel tired
and depressed.
It usually begins in adult life and lasts for
at least several years, sometimes
indefinitely.
The lifetime prevalence is approximately
3%, and it is more common in women.
F34.1 Dysthymie
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dysthymie: mírná chronická deprese
epidemiologie: celoživotní prevalence
kolem 3%
etiopatogeneze: faktory genetické i vnější
léčba: jako u depresivní poruchy –
kognitivně-bahaviorální psychoterapie,
antidepresiva
Treatment of Depression
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Various antidepressants altering levels of central
neurotransmitters are available to treat
depression.
Their overall effectiveness: 65-70%
Mild to moderate depressive episode: SSRIs.
Severe depression: antidepressants with broader
spectrum of effects, like SNRI or TCA.
Patients with insomnia or anorexia may do better
with more sedating medication (mirtazapine,
trazodon)
Patients with lethargy, hypersomnia, weight gain
and lower levels of tension and anxiety may
prefer the less sedating medications such as
bupropion, reboxetin or stimulating SSRIs.
IMAOs or RIMA should be tried in refractory
patients or patients with atypical depression.
Treatment of Depression
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Drug trials should last 4 to 8 weeks.
No response within 4 weeks of treatment - the
dose should be increased or the patient should be
switched to another drug.
In partial responders - augmentation strategy;
coadministration of lithium carbonate or
trijodthyronine.
Psychotic patient - adding on neuroleptics.
Anxious or agitated patients (also to improve the
sleep quality) - benzodiazepine coadministration
for a short period of time.
Lithium prophylaxis is an option to
antidepressants.
Supportive psychotherapy.
Treatment of Depression
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First episode of depression - the drug should be
continued for another 16-20 weeks after the patient
is thought to be well (continuation treatment to
prevent recurrence).
The medication should be tapered gradually because
many patients experience some mild withdrawal
effects.
Patients with recurrent depression need long-term
maintenance therapy to prevent relapses.
Electroconvulsive therapy (ECT) is the treatment of
choice for some patients with very severe
depression, with high potential for suicide or other
selfdestroying behaviour and for pregnant women.
Other biological methods:
• phototherapy (seasonal affective disorder)
• sleep deprivation
• repetitive transcranial magnetic stimulation (rTMS).
Treatment of Mania
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Mood stabilizers:
• lithium (0.6—1.2 mEq/L)
• carbamazepine (6—12 mg/L)
• valproate (50—125 mg/L)
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Anticonvulsants:
• gabapentine
• topiramate
• lamotrigine
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Agitated or psychotic patient –
coadministartion of
• antipsychotics of second generation
(olanzapine, risperidone)
• benzodiazepines (lorazepam, clonazepam)
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ECT