CHAPTER 4 MOOD DISORDERS: DEPRESSION AND MANIA -Every person experiences from time to time a change in his/her mood. This is considered normal as long as it is appropriate to life event. -Mood is considered abnormal when it is excessively depressed or related out of proportion to the life experience. -Normal grief: Feelings that are precipitated by loss of a loved one & can occur in response to a variety of losses. 1

Epidemiology of mood disorders: -2% of the general population develop a mood disorder. -21% of women & 13% of men develop major depression. -Average age of onset for bipolar illness is mid-late 20’s. -Depression occurs more frequently in lower socioeconomic groups. -Bipolar disorders occur more frequently in higher socioeconomic groups. 2

Etiologic factors related to mood disorders: 1. Neuro-biologic factors: -Altered neurotransmission. -Neuroendocrine dysregulation. -Geriatric transmission. 3

2. Psychosocial factors: a. Psychoanalytic theory: -Depression is a result of loss. -Mania is a defense against depression. b. Cognitive theory: -Depression is a result of negative processing of thoughts. 4

c. Learned helplessness: -Depression is a result of perceived lack of control over events. d. Life events and stress theory: -Significant life events cause stress that results in depression or mania. e. Personality theory: Personality characteristics predispose individual to mood disorder. 5

CLINICAL PICTURE -The key symptoms are depressed mood & loss of interest or pleasure in all or most of the activities. Diurnal Variation: Depressive symptoms change in severity during the day. They are worse in early morning hours, & improve as day passes. 6

Somatic Symptoms -Decreased appetite & weight loss, but in some cases pt. may have increased appetite & his weight may increase. -Sleep Disturbances (Insomnia): Early morning awakening, multiple awakening at night with difficulty to go back to sleep. Some patients may sleep most of the day (Hypersomnia). Decreased sexual interest and activity Low energy level: pt. can not start any activity & when he starts he soon loses interest or energy to complete it. 7

MENTAL STATUS EXAMINATION 1.GENERAL APPEARANCE a. Psychomotor Retardation: -Decreased activity level, spontaneous movements, stooped posture and sad facial expression. Severely retarded patients may look like catatonic schizophrenia. b. Psychomotor Agitation: -Occurs in old pts. with restlessness, hand wringing. 8

2. MOOD AND AFFECT -Depressed mood is the key symptom, some pts. may deny feeling depressed, but they are withdrawn and have decreased activity level. 3. SPEECH - Speech is slow, monotonous, & pt. answers in brief. He may not speak if not spoken to. 9

4. PERCEPTION -May occur in depression & pt. with hallucinations & delusions is said to have psychotic depression. -Usually hallucinations or pseudo-hallucinations of depressive content (Ex: Auditory hallucinations of a voice accusing pt. of being guilty or threatening him of punishment). -Illusions may occur in depression. Pt. misinterprets external stimuli to be accusing him. 10

5. THOUGHT -Depressed pts. have negative thoughts about themselves, the world and future (Cognitive Triad). -Preoccupation with thoughts of loss, worthlessness, guilt & death. - Suicidal ideation is present in 2/3 of depressed pts. & should be asked about. a. Poverty of thoughts: Some pts. have very little thoughts & may find difficulty in finding an answer to your question. 11

b. Delusions: Pt. may have delusions of guilt, or poverty.These are called mood congruent delusions because they are going with depressive mood. c. Process: thinking is slow and difficult, pt. may take a long time to answer a question. d. Orientation: Depressed pts. are usually oriented to x3. e. Memory: Approximately 75% of pts. complain of forgetfulness and poor concentration. 12

6. JUDGMENT AND INSIGHT: -Depressed pts. emphasize their symptoms, they are said to have excessive insight into their condition. 7. RELIABILITY: -Information from depressed patients tends to emphasize the bad and minimize the good. -Pt. may describe all his life as miserable and worthless and underestimate his achievement. 13

8. IMPULSE CONTROL AND SUICIDE: - Two thirds of depressed pts. have suicidal thoughts, & about 10 to 15% actually complete suicide. -A psychotic depressed patient may kill a person if his delusion includes that person. -Paradoxical Suicide: Is a suicide in a depressed pt. after starting antidepressant treatment and improvement in his activity level. -It is wrong to give a severely depressed pt. a large amount of pills to take at home. 14

MAJOR DEPRESSION Diagnosis: presence of five or more of the following symptoms at the same period which is not less than two weeks conditional by depressed mood or anhedonia should be one of them: 15

-Depressed mood most of the day, everyday “nearly”, pt. considers it as feeling of sadness or emptiness, while others observe pt. as crying one. -Noticeable decrease of interest or loss of pleasure toward most of the daily activities “nearly” everyday & most of the day “anhedonia”. -Significant wt. loss or gain or change in appetite “more than 5 % in a month”. -Insomnia or hypersomnia daily “nearly”. 16

-Psychomotor agitation or retardation daily “nearly”. -Exhaustion or loss of energy daily ”nearly”. -Diminished ability to think, concentrate or make decision. -Feelings of self-worthlessness, guilty feeling “inappropriate” which may become as delusion daily (nearly). -Recurrent thought of death “including thoughts of suicide”. 17

Prognosis -Depression increases at late twenties but can start at any age. -Could be sudden or gradual. -Different period : one attack may continue for six months or more (if not treated). -Prognoses is full improvement & pt. will be back to his previous social and vocational performance, but in some cases symptoms stay for 2 years without improvement (these attacks called chronic depression). -The most serious complication is suicide. 18

Dysthymic Disorder - Chronic mood disorder includes depression most of the day for most days for 2 years in adults & 1 year in children & adolescents (at least) in addition to some symptoms. 19

Diagnosis - Depression for most of the day ( most days ) for a period not less than 2 year in adults. -During the period of depression 2 or more of the following : -Loss or increase appetite -Insomnia or hypersomnia -Loss of energy or exhaustion (even usual activities which may reflect their beliefs they have physical problems). 20

-Low self esteem & inadequacy (guilt & brooding about the past). -Difficulty with concentration, memory, & decision- making. -Negative thinking evidenced by pessimism, despair and hopelessness. -Absence of episodes of mania, mixed, hypomania or major depression. -Symptoms cause clinical problems, social and vocational. 21

Notice: -It is difficult to differentiate b/w major depression & dysthymia because symptoms are the same. -In major depression, performance of pt. decreases significantly, but in dysthymia less severe & its effect on performance is less and may continue for years. - It is believed that 50 % of dysthymic pts. will have major depression later. 22

Treatment for depression 1- Drugs (Anti-depressant): a.Tricyclic Antidepressant ( TCA’S ) b.Monamine Oxidase Inhibitors ( MAO’s ) ECT -Especially for depression accompanied by suicidal ideation or major depression. 23

2- Psychotherapy: -Very important entrance in treating depression especially for relieving aggressive reaction against self & to decrease of hostility B/W Ego & Superego, to decrease guilty feeling & helping pt. to joint reality & not isolated, change his ideas & thoughts about self & others. -Connection b/w chemical treatment & psychotherapy is most effective in treating depression. 24

a- Cognitive psychotherapy: -Aims to help pt. to recognize & test negative cognition bout himself, world & future and to discover and progress methods in thinking more positive & more flexible. b- Psychoanalytic psychotherapy: -Aims to establish changes in personality structure, improving trust and improving the use of defense mechanisms. 25

c- Family therapy: -It is recommended if there is a relation b/w symptoms with pt. & reactions with his family. -Also it tests the role of pt. in his family and how the family affects on continuity of depression condition or not. 3-Social therapy: -Helping pt. socially & solving his social problems & establishing appropriate environmental changes to decrease his suffering. 26