1. Mood Disorders: A Biopsychosocial Approach
Katharine Gillis FRCPC
Associate Professor
Department of Psychiatry
University of Ottawa

2. MOOD DISORDERS Major Depressive Disorder Dysthymic Disorder
Bipolar Disorders:
I with Mania
II with hypomania
Cyclothymia

3. LIFETIMES PREVALENCES
Major Depressive Disorder
women %
men %
Dysthymia %
Bipolar Disorders
type I %
type II %

4. In the Family Practice Setting
25% of all patients who visit their family physicians will have a diagnosable mental disorder
The incidence of major depression is 10% in primary care patients
Effective treatment can reduce morbidity and decrease utilization of other health services
Medical patients with major depression have a worse prognosis for their medical recovery

5. Key Concepts in Mood Disorders
Mood Disorders are usually EPISODIC
Need to inquire about current episode, but also past episodes
Past history of episodes that are high or low are the often the key to sorting out the diagnosis
Genetics are very important in mood disorders especially Bipolar: ALWAYS ask about family history of mood symptoms or suicide

6. Key Concepts in Mood Disorders
Is there a history of inter episode wellness- better prognosis
Are the symptoms chronic
Treatment goal is to treat current symptoms but also to try and prevent future episodes of mood symptoms
Treatment usually medication based for moderate to severe symptoms plus or minus a specific type of psychotherapy.

7. How is Major Depression different from just feeling down?
Just feeling down should not have “physical symptoms” associated with it
Just feeling down should not impair function
Just feeling down should not last daily for at least two consecutive weeks or more
Untreated an episode of major depression on average lasts 6-12 months

8. Key Concept for Major Depression
For Major Depression must have persistent symptoms of depression or LOSS of INTEREST for at least 2 consecutive weeks
Many people with depression do NOT report feeling depressed, but have loss of interest
Elderly patients often have new onset of somatic complaints but may deny feeling depressed
Need a cluster of four other symptoms besides loss of interest or depression to make the diagnosis

9. Key Concept for Major Depression
Physical symptoms of depression include changes FROM BASELINE in sleep, appetite, energy and physical movements
Physical symptoms are often referred to as “vegetative symptoms”
The presence of new onset of vegetative symptoms can be a good predictor of response to antidepressant treatment

10. Physical Symptoms of Major Depression
Sleep- change from baseline. Usually too little.
All sleep phases can be effected but the classic symptom is early morning awakening.
Excessive sleep from baseline is an atypical feature and occurs more in teenagers

11. Physical Symptoms of Major Depression
Appetite-change from baseline usually a decrease
Loss of taste for food*
Loss of weight
Increase in appetite from baseline, especially with carbohydrate craving is an atypical feature and occurs more in teenagers

12. Physical Symptoms of Major Depression
Fatigue- change from baseline
Diminished spontaneous movements may be observed and is called psychomotor slowing
Physical restlessness may be observed and is called psychomotor agitation

13. Other Important Symptoms of Major Depression
Guilt
Impaired concentration
Social withdrawal
Suicidal thoughts: Safety assessment
Panic attacks*
Obsessive compulsive symptoms*
*Not in DSM-4 criteria

14. Specifiers for Mood Disorders
Specifiers describe the most recent mood episode such as:
With Postpartum Onset (within 4 weeks of delivery
With Catatonic features
With Atypical Features
With Rapid Cycling

15. Specifier- With Seasonal Pattern
Only applies to Major Depressive Episode (not manic or hypomanic)
Regular temporal relationship between onset of major depressive episode and a particular time of year usually fall or winter
Full remission also occurs at regular time of year usually spring (or switch to mania)
In the last 2 years two major depressive episodes have occurred as above with no nonseasonal episode of MDE occurring in the two years
Seasonal episodes of MDE outweigh nonseasonal episodes in their lifetime

16. Specifier-With Psychotic Features
Psychosis may be present in 10-15% of patients with a Major Depressive Episode
Associated with worse prognosis
Increase risk of suicide and homicide
Important to always screen for psychotic symptoms
Has treatment implications- antipsychotic needs to be added to antidepressant. May be an indication to consider ECT.

17. Epidemiology of Major Depression. Who is at risk?
Prevalence for men 5-12%, women 10-25%
Mean age of onset is around 40
50% of all patients have onset between the ages of 20 and 50
10% of post partum women are at risk of Major Depressive Episode. Etiology remains unclear, stress vs. hormone

18. Epidemiology of Major Depression. Who is at risk?
No correlation between socioeconomic status and MDE but unemployed are at 3X more risk
MDE more common in rural than urban areas
Prevalence of mood disorder does not vary among races
Loss of a parent before age 11 is a risk
Loss of a spouse is a risk

19. Recurrence Rates in Major Depression
After 1 episode %
After 2 episodes %
After 3 episodes % +

20. DYSTHYMIA Depressed mood most days for 2 years
Depressed symptoms include:
appetite disturbance
sleep disorder
fatigue
low self-esteem
poor concentration
hopelessness
indecision

21. DYSTHYMIA (cont.) Never symptom-free for over 2 months
Symptoms cause impaired functioning
Antidepressant may or may not be helpful. Psychotherapy may help particularly if many negative cognitions.

22. Bipolar Disorder
Bipolar disorder is characterized by the occurrence of mood episodes, usually with inter-episode wellness.
A mood episode can be a major depressive, manic, hypomanic, or mixed episode
An episode is demarcated by either switch to an opposite state ( manic to depressive) or 2 months or more of partial or full remission after an episode

23. Bipolar Type I Prevalence 1% of population men=women
Must have at least one Manic Episode
Does not require a depressive episode but most patients have depression in their lifetime
Most have more depressive than manic episodes
Manic episodes are not subtle and usually require hospitalization

24. Manic Episode Criteria
Elevated mood (may be irritable, expansive) persisting for at least one week
Need 3 (or 4 if irritable) of the following:
Grandiosity
Delusions
Reduced sleep
Talkative
Racing thoughts (flight of ideas)
Distractibility
Psychomotor agitation
Poor impulse control, excessive involvement in pleasurable activities

25. Manic Episode Criteria
Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features
Symptoms present at least one week
Condition not caused by general medical condition or substances

26. Mixed Episode Criteria
Criteria are met for both a manic episode and a major depressive episode (except for duration) nearly every day for 1 week
Severe, marked impairment in function at work or socially, or need for hospitalization or presence of psychotic features
Condition not caused by general medical condition or substances

27. Bipolar I Average onset for first manic episode is age 32
Most have had 2-3 episodes of depression by history prior to first manic episode
Symptoms of acute mania develop over hours to days
Untreated manic episode lasts 3 months
Untreated depressive episode lasts 6-13 months

28. Bipolar II Must have hypomanic episode(s) not manic
Prevalence 0.5 % population
May have major depressive episodes
Less functional impairment than Type 1
Often does not require hospitalization
If patient looks hypomanic but delusions present then diagnose as manic
Did an antidepressant cause the hypomanic symptoms? If so may be Bipolar III.

29. Hypomanic Episode
Elevated, expansive or irritable mood lasting at least 4 days
Need 3 (or 4 if irritable) of the following:
Grandiosity
Delusions
Reduced sleep
Talkative
Racing thoughts (flight of ideas)
Distractibility
Psychomotor agitation
Poor impulse control, excessive involvement in pleasurable activities

30. Hypomanic Episode Unequivocal change in functioning from baseline
The disturbance in mood and the change in functioning is observable by others
The episode is NOT severe enough to cause marked impairment in work or social functioning, or to need hospitalization, no psychotic features
Symptoms are not caused by a general medical condition or substances

31. Rapid Cycling Bipolar Disorder
Can be applied to Bipolar I and II
At least four mood episodes in previous 12 months- depression, mania, hypomania, mixed state
Episode demarcated by either switch to opposite state or 2 months of partial or full remission between episodes
Rapid cycling diagnosis has treatment implications

32. CYCLOTHYMIA
Numerous periods of depressive symptoms AND hypomania symptoms over 2 years
Never symptom free for 2 months
No time of Major Depression or Mania
Symptoms cause impaired functioning

33. Common Medical Conditions Associated with Mood Disorders
Hypo/hyper thyroidism
Cardiovascular disease especially MI
CNS- infection, tumour, stroke, head injury, hypoxia
Parkinson's, Huntington's, Multiple Sclerosis
B12, folate deficiency
Chronic pain
Sleep Apnea

34. Drugs Commonly Associated with Mood Disorders
Steroids, corticosteroids – depression, mania, anxiety
Accutane isoretinoin
Oral contraceptives, progesterone
Interferon A
Evidence for Beta Blockers is weak