1. Mood Disorders
Dr Joanna Bennett

2. Mood Disorders
Pervasive alterations in emotions that are manifested by depression, mania, or both, and interfere with the person’s ability to function normally

3. Mood Disorders
Major depression: 2 or more weeks of sad mood, lack of interest in life activities, and other symptoms
Bipolar disorder (formerly called “manic-depressive illness”): mood cycles of mania and/or depression and normalcy and other symptoms

4. Some related disorders
Seasonal affective disorder (SAD)
Postpartum depression
Postpartum psychosis

5. Prevalence International studies Major depression - 3-16%
Bipolar disorder %
Caribbean
4.9% (PAHO 2005)
Community prevalence and risk factors for mood disorders are generally unknown

6. DSM Diagnostic criteria – Major depressive disorder
At least one of the following three abnormal moods
significantly interferes with the person's life:
Depressed mood
Loss of interest & pleasure
Irritable mood (under 18 yrs)
Occurring most of the day, nearly every day, for at least 2 weeks

7. Diagnostic criteria: Depression
At least five of the following symptoms should have been present during the same 2 week depressed period:
Depressed or irritable mood
Loss of interest & pleasure
Appetite/weight disturbance (gain/loss)
Sleep disturbances
Fatigue/loss of energy
Guilt
Poor concentration
Morbid thoughts of death

8. Diagnostic criteria: Depression
The symptoms are not due to
Physical illness, alcohol, medication, or street drug use.
Normal bereavement.
Bipolar Disorder
Delusional or Psychotic Disorders
Abnormal depressed mood:
Sadness is usually a normal reaction to loss. However, in Major Depressive Disorder, sadness is abnormal because it:
Persists continuously for at least 2 weeks.
Causes marked functional impairment.
Causes disabling physical symptoms (e.g., disturbances in sleep, appetite, weight, energy, and psychomotor activity).
Causes disabling psychological symptoms (e.g., apathy, morbid preoccupation with worthlessness, suicidal ideation, or psychotic symptoms).
The sadness in this disorder is often described as a depressed, hopeless, discouraged, "down in the dumps," "blah," or empty. This sadness may be denied at first. Many complain of bodily aches and pains, rather than admitting to their true feelings of sadness.
Abnormal loss of interest and pleasure mood:
The loss of interest and pleasure in this disorder is a reduced capacity to experience pleasure which in its most extreme form is called anhedonia.
The resulting lack of motivation can be quite crippling.
Abnormal irritable mood:
This disorder may present primarily with irritable, rather than depressed or apathetic mood. This is not officially recognized yet for adults, but it is recognized for children and adolescents.
Unfortunately, irritable depressed individuals often alienate their loved ones with their cranky mood and constant criticisms.
Major Depressive Disorder causes the following physical symptoms:
Abnormal appetite:
Most depressed patients experience loss of appetite and weight loss. The opposite, excessive eating and weight gain, occurs in a minority of depressed patients. Changes in weight can be significant.
Abnormal sleep:
Most depressed patients experience difficulty falling asleep, frequent awakenings during the night or very early morning awakening. The opposite, excessive sleeping, occurs in a minority of depressed patients.
Fatigue or loss of energy:
Profound fatigue and lack of energy usually is very prominent and disabling.
Agitation or slowing:
Psychomotor retardation (an actual physical slowing of speech, movement and thinking) or psychomotor agitation (observable pacing and physical restlessness) often are present in severe Major Depressive Disorder.
Major Depressive Disorder causes the following cognitive symptoms:
Abnormal self-reproach or inappropriate guilt:
This disorder usually causes a marked lowering of self-esteem and self-confidence with increased thoughts of pessimism, hopelessness, and helplessness. In the extreme, the person may feel excessively and unreasonably guilty.
The "negative thinking" caused by depression can become extremely dangerous as it can eventually lead to extremely self-defeating or suicidal behavior.
Abnormal poor concentration or indecisiveness:
Poor concentration is often an early symptom of this disorder. The depressed person quickly becomes mentally fatigued when asked to read, study, or solve complicated problems.
Marked forgetfulness often accompanies this disorder. As it worsens, this memory loss can be easily mistaken for early senility (dementia).
Abnormal morbid thoughts of death (not just fear of dying) or suicide:
The symptom most highly correlated with suicidal behavior in depression is hopelessness

9. Mania: Signs and symptoms
Grandiose delusions, inflated sense of self-importance
Racing speech, racing thoughts, flight of ideas
Impulsiveness, poor judgment, distractibility
Reckless behavior
In the most severe cases, delusions and hallucinations

10. Mania: Signs and symptoms
Increased physical and mental activity and energy
Heightened mood, exaggerated optimism and self-confidence
Excessive irritability, aggressive behavior
Decreased need for sleep without experiencing fatigue

11. Types of Bipolar disorder

12. Diagnostic criteria: Mania
Persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
3 (or more) of the symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

13. Diagnostic criteria: Mania
inflated self-esteem or grandiosity
decreased need for sleep
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractibility
excessive involvement in pleasurable activities

14. Nursing diagnosis
Psychiatrists have formulated clear guidelines for categorizing mental disorders (DSM-1V, ICD-10) – determines interventions
Nursing diagnosis provides basis for nursing intervention
Systematic collection & integration of data to formulate Nursing Diagnosis
The Nurse combines nursing diagnoses and DSM/ICD classifications to develop the treatment plan

15. Nursing Diagnosis Assessment/psychiatric interview/MSE
Example nursing diagnosis
Risk for Suicide
Ineffective Coping
Hopelessness
Self-Care Deficit

16. Aetiology Depression often triggered by stressful life events
Contributing factors:
Intensity and duration of these events
individual’s genetic endowment
coping skills
social support network - depression and many other mental disorders are broadly described as the product of a complex interaction between biological and psychosocial factors

17. Biological factors Focus on alterations in brain function
Abnormal concentrations of many neurotransmitters and their metabolites in urine, plasma, and cerebrospinal fluid
Overactivity of the HPA (hypothalamus-pituitary-adrenal) axis - stress
dysfunction in serotonin (5-HT(1A) receptor activity could be due to a hypersecretion of cortisol
The results showed that a dysfunction in 5-HT(1A) receptor activity could be due to a hypersecretion of cortisol.
Major depression is associated with a dysfunction of the serotonergic activity and the hypothalamic-pituitary-adrenal (HPA) axis

18. Monoamine Hypothesis
Prevailing hypothesis - depression is caused by an absolute or relative deficiency of monoamine transmitters in the brain
Evidence that reserpine, a medication for hypertension, caused depression by depleting the brain of both serotonin and the three principal catecholamines (dopamine, norepinephrine, and epinephrine).

19. Monoamine Hypothesis
monoamine hypothesis remains important for treatment purposes.
Many currently available pharmacotherapies that relieve depression or mania, or both, enhance monoamine activity.
One of the foremost classes of drugs for depression, SSRIs, increase the level of serotonin in the brain.

20. Psychosocial and Genetic Factors in Depression
Social, psychological, and genetic factors act together to predispose to, or protect against, depression.
many episodes of depression are associated with some sort of acute or chronic adversity
past parental neglect, physical and sexual abuse, and other forms of maltreatment impact on both adult emotional well-being and brain function

21. Psychosocial and Genetic Factors in Depression
early disruption of attachment bonds can lead to enduring problems in developing and maintaining interpersonal relationships and problems with depression and anxiety.

22. Cognitive factors
how individuals view and interpret stressful events contributes to whether or not they become depressed.
the impact of a stressor is moderated by the personal meaning of the event or situation
Increased vulnerability to depression is linked to cognitive patterns that predispose to distorted interpretations of a stressful event

23. Genetic factors in depression & Bipolar
Susceptibility to a depressive disorder 2-4 times greater among the first-degree relatives of patients with mood disorder
The risk among first-degree relatives of people with bipolar disorder 6-8 times greater.

24. Genetic factors in depression & Bipolar
Does not prove a genetic connection.
First-degree relatives typically live in the same environment, share similar values and beliefs, and are subject to similar stressors, the vulnerability to depression could be due to nurture rather than nature

25. Treatment
50 to 70 % of depressed patients who complete treatment respond to either antidepressants or psychotherapies
Surveys consistently show that a majority of individuals with depression receive no treatment

26. Treatment The acute phase - 6 to 8 weeks medication
patients should be seen weekly or biweekly for monitoring of symptoms, side effects, dosage adjustments, and support
Psychotherapies during the acute phase for depression typically consist of 6 to 20 weekly sessions

27. Treatment - ECT 60 to 70 % response rate seen with ECT
Proposed to be useful with poor response to medication
depression is accompanied by potentially uncontrollable suicidal ideas and actions
The most common adverse effects are confusion and memory loss for events surrounding the period of ECT treatment.

28. Management- Maintenance
Medication
acute phase treatment and at least 6 months of continued treatment
TCA’s, SSRI’s, NARIs, MAOIs,
St John Wort (Herbal) as effective as antidepressants

29. Psychosocial interventions : depression
NICE Guidelines (2009)
Mild depression – psychological
Moderate depression – Medication or Psychological
Severe depression – CBT & medication

30. Drug Treatment - Bipolar
Lithium – Long-term
Anticonvulsants – carbamazipine (not shown to be effective in acute treatment)
Antidepressants – SSRIs (inaequate evidence of effectiveness)
Antipsychotics – olanzapine, rispiridone (effective short-term)

31. Psychosocial interventions - Bipolar
CBT - group /individual
12-14 sessions < depressive episodes
Family therapy
psychoeducation, communication skills training, and problem-solving skills training.