Dr. Moh’d Dabbas JBPsych, DPM, DCPsych
Head of Psychiatry Unit, Royal Medical Services
Mood Disorders Definition: Disorders characterised by mood disturbance (inappropriate depression or elation). Usually accompanied by abnormalities in thinking and perception arising out the mood disturbance.
Classification: I.
Bipolar affective disorder – Recurrent attacks of both mania and depression. (At least one manic/hypomanic episode required to make this diagnoses)
II.
Unipolar affective disorder – Recurrent attacks of depression only
III. Mixed affective states – Cases where manic and depressive symptoms occur simultaneously.
Mood Disorders Epidemiology: Age – depressive disorders:
Women: Highest prevalence rate between 35 & 45 years
Men: prevalence rate increases with age
Sex:
Bipolar affective disorders : men = women.
All depressive disorders: twice as common in women
Social class: More common in social classes I, II, and V Marital Status: More common in divorced or separated Prevalence rate: 5% of the general population.
Unipolar Mood Disorders Major Depressive Disorder, Single Episode: diagnosed when person has one major depressive episode and has never had a manic or hypomanic episode Major Depressive Disorder, Recurrent: 2 or more major depressive episodes that are separated by a period of at least 2 months during which the individual is not depressed Dysthymic Disorder: shares symptoms with major depression, but symptoms are milder and remain relatively unchanged over long periods of time (at least 2 years) Grief / bereavement
What is Depression? Abnormally depressed mood, loss of all interest and pleasure in activities, most of the day, nearly every day
Prevalence: ď ś 5 - 12% for men ď ś 10 - 25% for women
Mood Low
Mood High
+10
+5
Mood Rating
Daily Symptoms of Depression
Healthy 0
Mild Depression -5
Severe Depression -10 Time (days)
Depressive Disorder 20% treated without medications
20% treated with antidepressants 10% treated with tranquilizers
50% of patients never seek help
Clinical features of depressive disorders A. Biological features of depression 1. Sleep disturbances (EMW, initial insomnia, excessive) 2. Change in appetite 3. Change in weight 4. Change is psychomotor activity 5. Loss of energy and fatigue 6. Loss of libido 7. Change in bowel habit
Clinical features of depressive disorders
Cont.
B. Appearance: 1. Neglected dress and grooming 2. Facial features 3. Reduced rate of blinking 4. Reduced gestural movements 5. Downwards gaze, head inclined forwards B. Speech: 1. Poverty of speech 2. Hesitancy B. Mood: Subjectively and objectively depressed
Clinical features of depressive disorders
Cont.
E. Thoughts: 1. Morbid thoughts Concerned with the past, present and future 2. Poverty of thought 3. Suicide E. Psychotic features of depression: 1. Delusions: Delusions of guilt, poverty, hypochondriacal 2. Hallucinations Second person auditory hallucinations
Clinical features of depressive disorders Cont. G. Cognition: 1. Impaired attention and concentration 2. Poor memory G. Other psychiatric symptoms: 1. Phobic symptoms 2. Obsessional symptoms 3. Hysterical symptoms 4. Hypochondriacal preoccupations 5. Depersonalization
DSM-IV Diagnostic Criteria for Major Depressive Episode A. At least 5 of the following, during the same 2-week period, must include either (a) or (b): a. Depressed mood b. Diminished interest or pleasure c. Significant weight loss or gain d. Insomnia or hypersomnia e. Psychomotor agitation or retardation f. Fatigue or loss of energy g. Feelings of worthlessness
DSM-IV Diagnostic Criteria for Major Depressive Episode Cont. B. Symptoms do not meet criteria for a mixed episode (i.e. meets criteria for both manic and depressive episode) C. Symptoms cause clinically significant distress or impairment of functioning. D. Symptoms are not due to the direct physiologic effects of substance or a general medical condition.
In 1990 Depression was the 4th leading cause of disability worldwide. Now Depression is the 2nd leading cause of disability, after heart-related illness. The WHO estimates that by 2020, Depression will become the ‘single leading cause’ of disability worldwide.
Medical conditions associated with depression Endocrine/Metabolic
Neurological Alzheimer’s Cerebral Infarctions Dementia Huntington’s Multiple Sclerosis Parkinson’s disease Inflammatory Lupus Irritable Bowel
Cardiovascular Heart failure MI
Hypo/Hyperthyroidism B12, Iron Deficiency Cushing’s Syndrome Hypocalcemia Diabetes Uremia
Malignancies
Other
Brain Pancreas GI
AIDS/HIV Chr.Fatigue Sdr. Chronic Pain
Selected drugs associated with depression Anticonvulsants
CNS Depressants
Antihypertensives
Corticosteroids
Antineoplastic agents
Digitalis preparation
Antiparkinsonian drugs
Histamine (H2)-antagonists
Antipsychotics
Tuberculostatics
Bipolar Mood Disorders Mania Hypomania Recovered Recovering
Mixed Episode Continued Symptomatic
New Subsyndromal
Depression 8 Basic Clinical States
Bipolar Mood Disorders Bipolar I Disorder: Alteration between full manic episodes & major depressive episode Bipolar II Disorder: Major depressive episodes alternate with hypomanic episode. Cyclothymic Disorder: More chronic/less severe version of bipolar disorder that lasts at least 2 years; involves hypomanic and depressive symptoms that don’t meet criteria for full major depressive or manic episode Rapid cycling: when a person has at least 4 manic or depressive episodes per 1 year
Mood Disorders Mania: A. Biological features of mania 1. Sleep disturbance 2. Change in appetite 3. Change in Wt. 4. Change in psychomotor activity 5. Increase drive in work and pleasure activities 6. Increased energy without fatigue 7. Hypersexuality- disinhibition
Mood Disorders Mania: A. Appearance and behaviour 1. Clothing - bright colors 2. Untidy and disheveled appearance 3. Overactivity ďƒ¨ physical exhaustion 4. Reckless behaviour A. Speech Pressure of speech = over talkativeness A. Mood 1. Euphoria (infectious), or irritability and anger 2. Brief episodes of depression
Cont.
Mood Disorders Mania: D. Thought 1. Expansive ideas 2. Pressure of thought 3. Flight of ideas D. Psychotic features of mania 1. Delusions: grandiosity, persecutory or of reference 2. Hallucinations: 2nd person auditory hallucination D. Insight E. Other psychiatric disorders: Schneiderian 1st. rank of schiz.15%
Cont.
The DSM-IV Diagnostic Criteria Manic episodes are characterized by the following symptoms: At least 1 week of profound mood disturbance is present, characterized by elation, irritability, or expansiveness Three or more of the following symptoms are present: Grandiosity Diminished need for sleep Excessive talking or pressured speech Racing thoughts or flight of ideas
Cont.
The DSM-IV Diagnostic Criteria for mania Clear evidence of distractibility Increased level of goal-focused activity at home, at work, or sexually Excessive pleasurable activities, often with painful consequences The mood disturbance is sufficient to cause impairment at work or danger to the patient or others. The mood is not the result of substance abuse or a medical condition.
Mood Disorders Etiology: A. Genetic Family studies: 1st degree relatives Bipol.=15%-20% Unipol.=10%-15% Twin studies: Concord.rate Bipol.: MZ=79%, DZ=19% Unipol.: MZ=54%, DZ= 20% B. Biochemical theories A. Monoamine theories: Disturbance in CNS serotonin (5-HT) activity as an important factor. Other neurotransmitters implicated include norepinephrine (NE) and dopamine (DA). B. Endocrine abnormalities ( ↓ TSH,↑cortisol) C. Electrolyte disturbances
Serotonin and Norepinephrine may relate to different depressive symptoms o r e S
n i n to
Impulsivity Sex Appetite Aggression
Nor ep Anxiety Irritability Pain Cognitive function
Mood Emotion
i nep
hrin
e
Vigilance Motivation
May need different antidepressant actions for different symptoms/system involved in depression
Mood Disorders C. Psychological theories 1. Maternal deprivation 2. Relationships with parents 3. Psychoanalytic theory: Freud: Feeling of love and hostility are present at the same time (ambivalence). Regression to the oral phase of psychosexual development Psychodynamic theory: Mania is a defense against depression
Cont.
Mood Disorders
Cont.
Etiology… 4. Cognitive theory: Four types of cognitive distortion in depression: Arbitrary inference: Drawing a specific conclusion Without sufficient evidences.
Selective abstraction: Focus on a single details while ignoring others.
Over-generalization: Forming conclusions based on too little and too narrow experience.
Minimization and magnification: Under- or overvaluing the significance of a particular event.
5. Separation 6. Premorbid personality
Mood Disorders Etiology‌ D. Life event studies Bereavement, separation in the six moths prior to the onset of depression ď ś Body built Patients of pyknic (stocky and rounded) build are particularly prone to affective disorders (Kretschmer)
Cont.
Mood Disorders Management Physical Psychological Social
Antidepressant Drugs First-generation antidepressants 1. MARI = Monoamine re-uptake inhibitors e.g.: Imipramine Clomipramine Amitriptyline 2. MAOI = Monoamine oxidase inhibitors e.g.: Tranylcypromine Phenelzine
Second generation antidepressants e.g.: Maprotiline Mianserin
Selective Serotonin Re-uptake Inhibitors : SSRI
Fluoxetine Paroxetine Sertraline Citalopram Fluvoxamine
“Dual-Acting” Antidepressants: Venlafaxine Duloxetine Mirtazapine Bupropion Reversible Inhibition of Monoamines: Moclobemide
Ideal Drug Treatment S afety Tolerability Efficacy P rice
Mood Disorders Management Cont… Physical… Lithium carbonate Antiepileptics used as mood stabilizers Antipsychotics
Cont.
Physiological Treatments ď ą Electro-convulsive therapy (ECT): A brief electrical shock that induces a seizure; used therapeutically to alleviate severe depression when medication is not effective.
ď ą Transcranial Magnetic Stimulation (TMS): Magnetic field causes a weak electrical field and electrical current within the brain. Has been useful in some cases of depression.
Indications of ECT 1. Severe depression (psychotic or endogenous) Especially in the elderly 2. Schizophrenia Catatonic type 3. Mania 4. Parkinson’s Disease In general, drug therapy is the primary treatment ECT is used if drugs fail or are not tolerated
Mood Disorders Management… Psychological Psychotherapy: Supportive psychotherapy Individual dynamic psychotherapy Interpersonal psychotherapy Cognitive behavioral therapy (CBT) Social Rehousing Family support
Depression can be a fatal disease Most people who commit suicide are depressed Suicide is the second leading cause of death in adolescents Suicide among those with depressive disorders can exceed 15% Firearms r the most frequent method used in completed suicides 75% of people with depression can be successfully treated