1. Mood Disorders
1
LEARNING OBJECTIVES
After attending this presentation you will be able to:
1. Describe the term mood and affect.
2. Classify mood disorders.
3. Identify the sources of mood disorders.
4. Determine the main diagnostic criteria for depression.
5. Describe the proper management for depressive disorders.
3. Mood and affect
It can be useful to conceptualize the relationship between emotional affect and mood as being
similar to that between the weather (affect) and the season (mood).
Affect an immediately expressed and observed emotion.
A feeling state becomes an affect when it is observable, for example, as overall demeanor or tone
and modulation of voice. Affect is to be distinguished from mood, which refers to a pervasive and
sustained emotion.
Affect refers for the expressions of emotion objectively, while mood refers to innate emotional
experience over a more prolonged period of time.
Mood and Affective disorders can be classified as:
1. Bipolar Affective Disorders
2. Depressive Disorders
3. Depression in association with medical illness or alcohol and substance abuse
3
4. Bipolar affective disorder
Bipolar affective disorder, or manic-depressive illness (MDI), is a common, severe, and
persistent mental illness.
Manic episodes are feature at least 1 week of profound mood disturbance, characterized by
elation, irritability, or expansiveness.
At least 3 of the following symptoms must also be present :
Grandiosity
Diminished need for sleep
Excessive talking or pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal-focused activity at home, at work, or sexually
Excessive pleasurable activities, often with painful consequences
4
5. Bipolar affective disorder (cont.)
Hypomanic episodes are characterized by an elevated, expansive, or irritable mood of at least 4
consecutive days’ duration.
At least 3 of the following symptoms are also present :
Grandiosity or inflated self-esteem
Diminished need for sleep
Pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal-focused activity at home, at work, or sexually
Engaging in activities with a high potential for painful consequences
5
6. Depressive Disorders
The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) classifies the depressive disorders as
disruptive mood dysregulation disorder,
major depressive disorder (including major depressive episode),
persistent depressive disorder (dysthymia),
premenstrual dysphoric disorder, and
depressive disorder due to another medical condition.
This article focuses on major depressive disorder in adults
6
7. Epidemiology
United States statistics
The lifetime incidence of major depressive disorder in the United States is 20% in women and
12% in men.
In 2010, the Centers for Disease Control and Prevention (CDC) released a report estimating
the prevalence of current depression in adults from 2006-2008.
Of 235,067 adults, 9% met the criteria for current depression, including 3.4% who met the
criteria for major depression.
7
8. Pathophysiology
The underlying pathophysiology of major depressive disorder has not been
clearly defined.
Current evidence points to a complex interaction between neurotransmitter
availability and receptor regulation and sensitivity underlying the affective
symptoms.
Clinical and preclinical trials suggest a disturbance in central nervous system
serotonin (5-HT) activity as an important factor.
Other neurotransmitters implicated include norepinephrine (NE), dopamine
(DA), glutamate, and brain-derived neurotrophic factor (BDNF).
8
9. Pathophysiology (cont.)
Endocrine changes in depression are evident across the life span,
but some are unique to aging.
Women with a previous history of depression are at higher risk of
developing depression during menopause, although estrogen
replacement does not relieve depression; low testosterone levels
have been associated with depression in older men.
9
10. Etiology
The specific cause of major depressive disorder is not known.
Major depressive disorder appears to be a multifactorial and heterogeneous group of
disorders involving both genetic and environmental factors.
Genetics
Genetic factors play an important role in the development of major depression. Evidence
from twin studies suggests that major depression has a concordance of 40-50%.
Two susceptibility loci have been identified in which no specific gene of interest has been
definitively identified. The MDD1 locus is located at 12q22-q23.2 and is most strongly linked to
major depression in males. The MDD2 locus is located at 15q25.2-q26.2 and has been
associated with early onset or recurrent episodes of depression.
Stressors
Chronic pain, medical illness, and psychosocial stress can also play a role in major depressive
disorder.
10
11. Presentation
History
Familial, social, and environmental factors
Dysphoric mood
Psychosis
Physical Examination
a complete mental health evaluation should always include a medical evaluation to rule out organic
conditions that might imitate a depressive disorder.
Most of these fall into the following major general categories:
Infection
Medication
Endocrine disorder
Tumor
Neurologic disorder
Appearance and affect
Speech
11
12. Dysthymic
Dysthymic disorder is a depressive mood disorder characterized by a chronic course and an insidious onset.
By definition, this condition has a duration of at least 2 years in adults and 1 year in adolescents.
It is manifested as a depressed mood, or irritable mood in children, for most of the day, occurring more days
than not, and is accompanied by at least 2 of the following symptoms :
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration and/or difficulty making decisions
6. Feelings of hopelessness
The DSM-IV-TR categorizes dysthymia according to course specifiers.
These include:
1. early onset if symptoms began before age 21 years,
2. late onset if symptoms began at age 21 years or later, and
3. dysthymia with atypical features if symptoms include increased appetite or weight gain, hypersomnia, a
feeling of leaden paralysis, and extreme sensitivity to rejection
12
13. Major Depressive Disorder
The specific DSM-5 criteria for major depressive disorder are outlined below.
At least 5 of the following symptoms have to have been present during the same 2-week period (and at
least 1 of the symptoms must be diminished interest/pleasure or depressed mood) :
1. Depressed mood: For children and adolescents, this can also be an irritable mood
2. Diminished interest or loss of pleasure in almost all activities (anhedonia)
3. Significant weight change or appetite disturbance: For children, this can be failure to achieve expected weight gain
4. Sleep disturbance (insomnia or hypersomnia)
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness
8. Diminished ability to think or concentrate; indecisiveness
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan
for committing suicide
The symptoms cause significant distress or impairment in social, occupational or other important areas of
functioning.
The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional
disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders
There has never been a manic episode or a hypomanic episode.
13
14. Postpartum Depression
Depression in the postpartum period is a common and potentially very serious problem; up to
85% of women can develop mood disturbances during this period.
For most women, symptoms are transient and relatively mild (ie, “postpartum blues”);
however, 10-15% of women experience a more disabling and persistent form of depression,
with an onset later than the postpartum blues, and 0.1-0.2% of women experience
postpartum psychosis.
Seasonal Affective Disorder
About 70% of depressed people feel worse during the winter and better during the summer.
To meet the DSM-5 diagnostic criteria for major depressive disorder with seasonal pattern,
depression should be present only at a specific time of year (e.g., in the fall or winter) and full
remission occurs at a characteristic time of year (e.g., spring). Patients with seasonal affective
disorder are more likely to report atypical symptoms, such as hypersomnia, increased
appetite, and a craving for carbohydrates.
14
16. Screening Tests
The following 2-question test addresses depressed mood and anhedonia:
1. During the past month, have you been bothered by feeling down, depressed, or hopeless?
2. During the past month, have you been bothered by little interest or pleasure in doing things?
Longer self-report screening instruments for depression include the following:
PHQ-9 – The 9-item depression scale of the Patient Health Questionnaire; each item is scored 0
to 3, providing a 0 to 27 severity score
Beck Depression Inventory (BDI) – A 21-question symptom-rating scale
BDI for primary care – A 7-question scale adapted from the BDI
Zung Self-Rating Depression Scale – A 20-item survey
Center for Epidemiologic Studies-Depression Scale (CES-D) – A 20-item instrument that allows
patients to evaluate their feelings, behavior, and outlook from the previous week
16
17. Management
Pharmacologic Therapy for Depression
Psychotherapy
Electroconvulsive therapy
Stimulation techniques
Drugs used for treatment of depression include the following:
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin/norepinephrine reuptake inhibitors (SNRIs)
Atypical antidepressants
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)
17
18. Serotonin/norepinephrine reuptake inhibitors
SNRIs, which include:
1. venlafaxine,
2. desvenlafaxine,
3. duloxetine, and
4. levomilnacipran
can be used as first-line agents, particularly in patients with significant fatigue or pain
syndromes associated with the episode of depression.
SNRIs also have an important role as second-line agents in patients who have not
responded to SSRIs.
The safety, tolerability, and side-effect profiles of SNRIs include those of the SSRIs, as
well as noradrenergic side effects, such as hypertension.
In July 2013, the FDA approved the newest SNRI levomilnacipram which is available
as a once-daily sustained-release formulation. It has greater potency for
norepinephrine reuptake inhibition than for serotonin reuptake inhibition without
directly affecting the uptake of dopamine or other neurotransmitters.
18
19. Psychotherapy
Types of psychotherapy that have been used for the treatment of major depressive
disorder, especially in the pediatric population, include the following:
Behavior therapy
Cognitive-behavioral therapy
Family therapy
Group psychotherapy
Interpersonal psychotherapy
Interpersonal therapy
Psychodynamic psychotherapy
Supportive psychotherapy
In mild cases, psychosocial interventions are often recommended as first-line treatments.
19
20. Prognosis
Major depressive disorder has significant potential morbidity and mortality, contributing as it does
to suicide, incidence and adverse outcomes of medical illness, disruption in interpersonal
relationships, substance abuse, and lost work time. With appropriate treatment, 70-80% of
individuals with major depressive disorder can achieve a significant reduction in symptoms,
although as many as 50% of patients may not respond to the initial treatment trial.
Suicide
According to Centers for Disease Control and Prevention (CDC) data , suicide was the 10th
leading cause of death in the United States in 2009, accounting for 36,909 deaths; it was the
second leading cause of death in people 25-34 years of age, the third leading cause in
people aged 10-24 years, and the fourth leading cause at ages 35-54.
20
21. Conclusion
The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5). classifies the depressive disorders as disruptive mood dysregulation disorder, major
depressive disorder (including major depressive episode), persistent depressive disorder
(dysthymia), premenstrual dysphoric disorder, and depressive disorder due to another medical
condition.
The differential diagnosis for depression includes other psychiatric disorders, CNS diseases,
endocrine disorders, drug-related conditions, infectious and inflammatory diseases, and sleep-
related disorders.
Depression screening tests can be used to screen for depression and bipolar disorder. The most
widely used is the Patient Health Questionnaire-9 (PHQ-9). It is important to understand that the
results obtained from the use of any depression rating scales are imperfect in any population,
especially the geriatric population.
All antidepressants approved by the FDA for use in major depression have proven to be effective,
although predicting what an individual patient’s response to a particular agent will be is difficult.
21