Shaul Lev-Ran, MD Shalvata Mental Health Center Affective disorders Shaul Lev-Ran, MD Shalvata Mental Health Center

Major Depressive disorder Dysthymic disorder Cyclothymia Bipolar II disorder Bipolar I disorder

Major depressive disorder Prevalence=15% F>M Mean age of onset=40 Genetic 1st degree relative of MDD – 2-3 times the chance of suffering from MDD

Depression is 2nd only to IHD as major cause of disability and early death in industrialized countries

Major Depressive Episode 5 of the following for at least 2 wks: 1. depressed mood 2. markedly diminished interest or pleasure 3. psychomotor disturbances 4. fatigue/loss of energy 5. feelings of worthlessness or guilt 6. suicidal thoughts or attempt 7. weight loss 8. sleep disturbances 9. difficulty concentrating, thinking, or deciding

Consequences Functional impairment Morbidity and mortality self family occupational financial Morbidity and mortality Worse outcome of disease than control Cardiac – independent prognostic factor Sudden death suicide

Specifiers describing depressive episode With psychotic features With melancholic features With atypical features With catatonic features Postpartum onset

Treatment - goals 5 X R (achieve) Response (achieve) Remission (achieve) Recovery (prevent) Relapse (prevent) Recurrence

Treatment-strategies What, where & how? (focus, locus, modus): What – major concerns, type of depression Where? Suicidal risk Support system Compliance Psychosocial stressors Level of functional impairment

What= Biopsychosocial approach: Bio=medication, others (ECT, TMS, VNS…) Psycho= Explaining the diagnosis Treatment plan and objectives Assessment Advantages: deals with secondary consequences (marital discord, occupational difficulties), adherence to medication Social=couples, family, occupational, etc.

Prognosis Untreated episode – 6-13 months Treated episode – 3 months Tends to be chronic – 25% recurrence in 6 m. after discharge 50% recurrence in 2 yrs. 75%recurrence in 5 yrs.

Bipolar I disorder Prevalence=1% M=F Mean age of onset=30 At least 1 manic episode Most often starts with depressive episode 10-20% - only manic episodes Genetic 1st degree relative with BP – 8-18 times the chance for BP 1 parent with BP – 25% chance of affective dis. 2 parents with BP – 50-75% chance of affective dis.

Manic episode Abnormally elevated, expansive or irritable mood lasting 1 wk. or requiring hospitalization. At least 3 of the following: Inflated self esteem or grandiosity More talkative/pressure to keep on talking Flight of ideas (including subjective feeling) Distractability Increase in goal directed activity Excessive involvement in pleasurable activity with high potential for painful consequence

Mixed episode The criteria for both manic episode and MD episode are met nearly every day for at least one week

Specifiers describing recurrent episodes Rapid cycling -4 or more episodes in 1 yr. With seasonal pattern

Affective disorders Major Depressive disorder (unipolar) Major depressive episodes Dysthymic disorder Milder & more chronic depression Cyclothymia Hypomanic episodes and milder depression Bipolar II disorder Hypomanic episodes and major depressive episodes Bipolar I disorder Manic episodes and major depressive episodes

Bipolar II disorder Includes at least one hypomanic episode: Lasting at least 4 days Criteria similar to manic episode The episode is not severe enough to cause marked impairment in functioning and there are no psychotic features

Dysthymic disorder At least 2 years No major depressive episode for first two years 2 of the following Eating disturbances Sleeping disturbances Fatigue/low energy Low self esteem Poor concentration or difficulty making decisions Feelings of hopelessness

Cyclothymia At least two years of hypomanic and minor depressive episodes No major depressive, manic or mixed episode for first two years

Treatment-strategies Where, what & how? (focus, locus, modus): Where? Danger to self and others Significant harm to self or others Support system Compliance Psychosocial stressors Level of functional impairment

What= Biopsychosocial approach: Bio=medication, others (ECT, TMS, VNS…) Psycho= Explaining the diagnosis Treatment plan and objectives Assessment Advantages: deals with secondary consequences (marital discord, occupational difficulties), adherence to medication Social=couples, family, occupational, etc.