Post on 20-Jan-2016
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
01020
30405060708090
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
“It is unfortunate that I didn’t get
your care earlier, Mrs. Perkins.”
Treatment
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?– Augment?– New drug?
Lithium
Thyroid hormone
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