Mood Disorders syndrome rather than medical condition
 MC MAJOR psychiatric disturbance
 Early recognition and intervention important in rapid onset
 No racial prevalence, however:
o Tend to under diagnose mood disorder, and over diagnose schizophrenia in backgrounds that differ from one’s own.
Depression: Significant functional impairment
1. Major depressive disorder
2. Persistent depressive disorder  Replaces “Dysthymia” (mild persistent depression)
3. Disruptive mood dysregulation disorder  Replaces “Childhood bipolar disorder”
4. Pre-Menstrual dysphoric disorder
Major Depression:
10-15% prevalence in primary care pts (25% women)
50% reoccurrence (within 6 mos) – can have 5-6 significant episodes in 20y period
o Between episodes pts function at their “normal”
o Frequency and length of episode increases with age
25% seek help; 75-80% pts are treatable
o If untreated: usually self-limiting and lasts 6-12 months
15% commit suicide
Up to 50% unaware or deny depression
Dx:
5+ symptoms present in 2 week period
May present with psychosis but delusions/hallucinations are uncommon
At least one symptom must be present:
o Depressed mood OR loss of interest in pleasure
Additional Criteria:
o Sleep disturbance: insomnia or hypersomnia
o Interest waning: or diminished pleasure
o Concentration: decreased focus or ability to think
o Psychomotor: agitation (excited) or retardation (slowed)
o Appetite: weight loss or gain (5% in a month)
o Guilt: or feeling of worthlessness
o Energy: loss of energy or fatigue
o Suicidal: ideation, recurrent thoughts of death, or attempt – risk may increase w/ treatment (↑ energy)
 ALWAYS ASK ABOUT SUICIDE
Important Info:
o Family hx
o PMH
o Medical sxs
o Stressors
o Level of functioning
o Alcohol/drugs
Ddx:
o Substance use (sedatives)/dependence or stimulant withdrawal
o Hypothyroidism
o Medications: reserpine, propanalol, methyldopa, steroids
o Malignancy/disease
Associated conditions:
o Cancers: pancreatic cancer may initially present as depression
o Renal, cardio/pulm disorders, endocrine
o Infectious: HIV, pneumonia, influenza, mono
o Neurologic: Parkinson’s, MS, stokes (esp. frontal lobe)
o Psychiatric: anxiety, schizophrenia, eating disorders
Case:
40-yo woman lost interest in work and social life, has lack of energy, lack of motivation and appetite, admits to thoughts
of suicide, and feels hopeless/helpless most of the time. Feels between in the evening than in the morning (diurnal
variation in sxs)
Treatment: all take 3-6 weeks to take effect
-
Heterocyclic antidepressants: (ACID)
o Major SEs: sedation, anticholinergic effects, CV effects (orthostatic hypotension), weight gain
 Amitriptyline (Elavil) 75-300 mg/day: depression w/ anxiety
 Clomipramine (Anafranil) 100-250 mg/day: OCD
 Imipramine (Tofranil) 75-300 mg/day: panic disorder with agoraphobia, enuresis, anorexia, and bulimia
 Desipramine (Norpramin) 75-300 mg/day: depression in the elderly, anorexia, bulimia
-
SSRIs:
o
o
OCD, premature ejaculation, and panic disorder
Major SEs: activation & insomnia, sexual problems/delayed orgasm (men), anticholinergic, CV, minor weight gain
 Paroxetine (Paxil) 20-50 mg/day
 Fluoxetine (Prozac) 20-80 mg/day – MC (more tolerable SEs)
 Sertraline (Zoloft) 50-200 mg/day
-
MAOIs: (TIP)
o Atypical depression, panic disorder, eating disorder, or pain disorder
o Major SEs: hypertensive crisis with tyramine rich foods (beer, wine, cheese)
 Tranylcypromine (Parnate) 20-60 mg/day
 Isocarboxazid (Marplan) 10-50 mg/day
 Phenelzine (Nardil) 30-90 mg/day
-
Other antidepressants:
 Alprazolam (Xanax) 2-6 mg/day: anxiety w/ depression
 Amoxapine (Asendin) 75-400 mg/day: depression w/ psychosis
 Bupropion (Wellbutrin) 300-600 mg/day
 Nefazodone (Serzone) 300-600 mg/day: intolerant to other antidepressants
-
Electro-convulsion therapy:
o Induces 25-60s long seizures
o Dose: 8 Treatments over 2-3 weeks
o Unilateral (non-dominant hemisphere) or bilateral
o Major SEs: amnesia (resolves within 6 mos)
o Indication:
 Refractory to antidepressants
 Rapid resolution of sxs – for high suicide risk
o Contraindicated: in increased cranial pressure
o Antidepressants or ECT 1-2x a month for maintenance
-
Psychotherapy: (interpersonal or family)
o Most effective as adjunct w/ medication
-
Hospitalization:
o Indications:
 High suicide risk
 Unable to care for themselves
 Poor support systems
 Decline in fxning
Disruptive Mood Dysregulation Disorders: (Replaces “Childhood Bipolar”)
Dx: in children up to 18
Sxs: persistent irritability, episodes of extreme/out-of-control behavior
Premenstrual Dysphoric Disorder:
Dx: occurs in most menstrual cycles during the past year
Sxs: improve within a few days of menses and are minimal/absent one week post menses
-
Includes 5+ marked sxs during week before menses – w/ at least one of the first four sxs
o (1) Affective liability (mood swings; suddenly sad, tearful, or increased sensitivity to rejection)
o (2) Irritability or anger or increased interpersonal conflicts
o (3) Depressed mood, feelings of hopelessness, or self-deprecating thoughts
o (4) Anxiety, tension, feelings of being “keyed up” or “on edge”
o (5) Decreased interest in usual activities ( work, school, friends, hobbies)
o (6) Subjective sense of difficulty in concentration
o (7) Lethargy, easy fatigability, lack of energy
o (8) Change in appetite, overeating, or specific food cravings
o (9) Hypersomnia or insomnia
o (10) Subjective sense of being overwhelmed or out of control
o (11) Other physical symptoms: breast tenderness or swelling, joint/muscle pain, “bloating” or weight gain
Bipolar Disorder
Criteria:
 Distractibility and easy frustration
 Irresponsibly and erratic, uninhibited behavior
 Grandiosity
 Flight of ideas or manic, rapid thoughts
 Activity increased (w/ weight loss or increased libido)
 Sleep decreased
 Talkativeness
-
Risks:
-
Manic episode = elevated mood for 7 days or more w/ at least 3 sxs (4 if irritable)
Hypomanic episode = elevated mood for 4 days or more w/ at least 3 of the sxs (4 if irritable)
o NO functional impairment (but change in fxn appreciated by others) – EXCEPT in BD II
Rapid cycling of episodes (at least 4 episodes per year) – 10-20% pts
 More treatable
 2/3rd are women
7% if one first degree relative; ~49% w/ two parents
1% if one second degree relative (aunt/uncle, grandparent)
Causes for exclusion: another medical cause or substance abuse/medication
Types:
-
-
-
BD I: (more severe)
o F=M
o Prevalence: 0.4 -1.6%
o Onset: 18 yoa
o Criteria:
 1+ manic episodes
 Major depressive episode = not necessary
BD II: (less severe)
o F>M
o Prevalence: 0.4-1.6%
o Onset: Mid 20s
o Criteria:
 1+ hypomanic episodes
 1+ major depressive episodes
Cyclothymic: (steady state)
o F=M
o Prevalence: 0.4-1.0%
o Onset: adolescence/early adulthood
o Criteria: 2 years of subsyndromal depression + hypomania
Mixed Disorders:
-
If either criteria is met, DX = manic w/ mixed features
o Dysphoric mania OR Activated depression
Treatment:
Old Standard = mood stabilizer + reuptake blocker
Lithium: more favorable in tx-naïve cases (1st course)
C/I: NSAIDs
Needs to check renal fxn
Teratogenic: 1st trimester  Ebstein’s anomaly (defective
tricuspid valve)
Valproic acid (Depakote): better for mixed episodes
Can cause PCOS in young women
Teratogenic: neural tube defects
Other side effects:
Chlorpromazine (Thorazine): auto-induction, agranulocytosis
Lamotrigine (Lamictal): OCP interaction and can cause SJS;
interacts with VA
Adjuncts: combo drugs useful in acute stabilization
Antipsychotics: required when psychotic episodes
Benzos: sedative, relaxant
ECT: can be used
Manic: reuptake blockers or Lamictal (v. useful)
Other features of BD:
60% manic episodes immediately preceded by major depressive episode
Major depressive episodes usually significantly outnumber hypomanic and manic episodes
35% suicidal  15% successful (15x greater risk than population) – BD II more lethal attempts
Consider other medical reasons: do baseline tests (CBC, chem, TSH, B12, tox screen, HCG, HIV/ELISA)
Similar to depression
Autoimmune: SLE
#1 Substance induced depression = ALCOHOL
Drugs: Steroid, B-blockers, antidepressants
Adjustment Disorder:
Develops in response to a stressor (w/in 3 months)
Terminates w/in 6 months of end of stressor
Distress out of proportion to stressor
May cause significant impairment
Similar to acute stress (ASD) or PTSD but not as severe