1. IzBen C. Williams, MD, MPH Instructor

2. Lecture - 8 MOOD DISORDERS

3. MOOD DISORDERS

4. DEFINITIONS: The essential feature of mood disorders is a disturbance of one’s emotional state along the happy-sad axis causing subjective distress and problems in functioning.

5. MOOD DISORDERS DEFINITIONS: Subjectively, the person may feel:  Somewhat worse than would be expected (dysthymia)  Very much worse than would be expected (depression)  Somewhat better than would be expected (hypomania)  Very much better than would be expected (mania)

6. MOOD DISORDERS

7. DIAGNOSIS: The diagnosis of mood disorder requires the identification of mood episodes, which are building blocks for making a diagnosis of mood disorder. Mood episodes: A. Major depressive episode (MDE) B. Manic episode C. Mixed episode D. Hypomanic episode

8. MOOD DISORDERS EPIDEMIOLOGY: There are no differences in the occurrence of mood disorders associated with ethnicity, education, marital status, or income. The lifetime prevalence of mood disorders is: A. Major depressive disorder: M 5-12% and F 10-20% B. Bipolar disorder: 1% overall, no sex difference C. Dysthymic disorder: 6% overall; M : F = 1 : 3 D. Cyclothymic disorder: < 1% overall; no sex difference

9. MOOD DISORDERS Major Depressive Disorder Characteristics: Recurrent episodes of depression, each continuing for at least two weeks Signs and Symptoms of Depression (qv) S – sadness, sleep, I – interests in pleasurable activity G – guilt and negativity E – energy, C – cognitive problems (eg. Concentration and memory) A – appetite, anhedonia, anger (at self), anxiety P – Psychomotor, poor grooming, psychotic symptoms (sometimes) S - suicidality

10. MOOD DISORDERS Major Depressive Disorder Characteristics: Recurrent episodes of depression, each continuing for at least two weeks Symptoms of depression (qv) Masked depression: being unaware of or in denial of depression; (50% of depressed patients) Usually complain to 1° care doctor of vague physical symptoms These complaints may be mistaken for hypochondriasis Seasonal affective disorder (light Tx) Suicide risk (see table of risk factors for suicide)

11. MOOD DISORDERS Major Depressive Disorder Associated clinical features: Psychotic features (mood congruent) Melancholia (profound anhedonia and neurovegetative symptoms. Significant wt. loss) Mortality and morbidity (additional risk of illness or death due to medical causes) Psychiatric comorbidity

13. MOOD DISORDERS Dysthymic Disorder Diagnosis: chronic depression (at least two years duration) but not severe enough to meet the criteria for MDE. Requires only 2 rather than 5 MDE symptoms. Associated clinical features: social impairment, health problems, abuse of alcohol and other drugs, major depression (double depression)

14. MOOD DISORDERS Bipolar I Disorder Bipolar I Disorder (misnomer) Diagnosis: at least one manic or mixed episode Associated clinical features: Psychotic features (mood congruent) Morbidity and Mortality Psychiatric comorbidity Epidemiology: Mean age of occurrence 21 yrs; Likelihood of recurrence 90%

15. MOOD DISORDERS Bipolar II Disorder Diagnosis: at least one MDE and one hypomanic episode in the absence of manic or mixed episodes. Associated clinical features: suicide risk particularly during depressive episodes

16. MOOD DISORDERS Cyclothymic Disorder Dysthymia with intermittent hypomanic episodes. Like dysthymia it is chronic rather than episodic Diagnosis: experienced over at least two years at least one MDE and one hypomanic episode in the absence of manic or mixed episodes. Associated features: substance abuse and social and occupational dysfunction are commonly seen Epidemiology: up to 50% may ultimately develop bipolar disorder

17. MOOD DISORDERS

19. Etiology: Etiology: The etiology is multifactorial Biologic Genetic factors (family studies, adoption studies) Neurochemical factors (NE, 5-HT and less solidly Dopamine); and other neurotransmitters such as GABA and neuropeptides also implicated Other biologic factors (neuroendocrine regulation, sleep and circadian rhythm, kindling

20. Bipolar disorder The Genetics of Bipolar Disorder GROUP% Occurrence The general population1% Person with one bipolar parent or sibling (or dizygotic twin)20% Person with two bipolar parents60% Monozygotic twin of a person with bipolar disorder75%

21. MOOD DISORDERS Etiology: Psychosocial: Stress Loss of a parent before age 11, linked to depression in adulthood Anger turned inward, intrapsychic processing of loss ….depression and self hatred Learned helplessness, (animal model) Negative cognitions

22. MOOD DISORDERS Treatment: Overall treatment planning: Mood disorders vary in symptoms and severity, but some overall guidelines exist Treatment setting Diagnostic evaluation Assessment of safety

23. MOOD DISORDERS Treatment: Treatment of major depressive disorder: Hospitalization: may become necessary for safety, treatment (including ECT), or support Outpatient treatment: combination of ψTx and medication, there are several models of ψTx for depression, support in its various forms Somatic therapies (medication and ECT)

24. MOOD DISORDERS Treatment: Treatment for bipolar I and Bipolar II disorders: Hospitalization: containment of manic behavior, initial or reinstituted treatment, compliance Outpatient treatment: combination of ψTx and medication, Somatic therapies: Lithium, Valproate, Carbamazepine, et al Other drugs: antipsychotics, benzodiazepines, antidepressants

25. Mood Disorder Vignettes 1.Major Depression https://www.youtube.com/watch?v=4YhpWZCdiZc 2.Manic Depressive Disorder: commentary https://www.youtube.com/watch?v=cqMcAeLWO9c 3.Manic episode https://www.youtube.com/watch?v=zA-fqvC02oM